1
|
Cai S, Xing H, Wang Y, Wang Y, Ma W, Jiang Y, Li J, Wang H. Clinical application of intraoperative ultrasound superb microvascular imaging in brain tumors resections: contributing to the achievement of total tumoral resection. BMC Med Imaging 2024; 24:142. [PMID: 38862900 PMCID: PMC11165841 DOI: 10.1186/s12880-024-01321-5] [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: 11/06/2022] [Accepted: 06/04/2024] [Indexed: 06/13/2024] Open
Abstract
BACKGROUND To investigate whether the intraoperative superb microvascular imaging(SMI) technique helps evaluate lesion boundaries compared with conventional grayscale ultrasound in brain tumor surgery and to explore factors that may be associated with complete radiographic resection. METHODS This study enrolled 57 consecutive brain tumor patients undergoing surgery. During the operation, B-mode and SMI ultrasound evaluated the boundaries of brain tumors. MRI before and within 48h after surgery was used as the gold standard to evaluate gross-total resection(GTR). The ultrasound findings and GTR results were analyzed to determine the imaging factors related to GTR. RESULTS A total of 57 patients were enrolled in the study, including 32 males and 25 females, with an average age of 53.4 ± 14.1 years old(range 19 ~ 80). According to the assessment criteria of MRI, before and within 48 h after the operation, 37(63.9%) cases were classified as GTR, and 20(35.1%) cases were classified as GTR. In comparing tumor interface definition between B-mode and SMI mode, SMI improved HGG boundary recognition in 5 cases(P = 0.033). The results showed that the tumor size ≥ 5 cm and unclear ultrasonic boundary were independent risk factors for nGTR (OR>1, P<0.05). CONCLUSIONS As an innovative intraoperative doppler technique in neurosurgery, SMI can effectively demarcate the tumor's boundary and help achieve GTR as much as possible.
Collapse
Affiliation(s)
- Siman Cai
- Department of Medical Ultrasound, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, 100730, China
| | - Hao Xing
- Department of the Neurosurgery Department, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, 100730, China
| | - Yuekun Wang
- Department of the Neurosurgery Department, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, 100730, China
| | - Yu Wang
- Department of the Neurosurgery Department, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, 100730, China
| | - Wenbin Ma
- Department of the Neurosurgery Department, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, 100730, China
| | - Yuxin Jiang
- Department of Medical Ultrasound, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, 100730, China
| | - Jianchu Li
- Department of Medical Ultrasound, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, 100730, China.
| | - Hongyan Wang
- Department of Medical Ultrasound, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, 100730, China.
| |
Collapse
|
2
|
Barbagallo GM, Maione M, Peschillo S, Signorelli F, Visocchi M, Sortino G, Fiumanò G, Certo F. Intraoperative computed tomography, navigated ultrasound, 5-amino-levulinic acid fluorescence and neuromonitoring in brain tumor surgery: overtreatment or useful tool combination? J Neurosurg Sci 2024; 68:31-43. [PMID: 31298506 DOI: 10.23736/s0390-5616.19.04735-0] [Citation(s) in RCA: 14] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Brain tumor surgery is routinely supported by several intraoperative techniques, such as fluorescence, brain mapping and neuronavigation, which are often used independently. Efficacy of navigation is limited by the brain-shift phenomenon, particularly in cases of large or deep-sited lesions. Intraoperative imaging was introduced also to update neuronavigation data, to try and solve the brain-shift phenomenon-related pitfalls and increase overall safety. Nevertheless, each intraoperative imaging modality has some intrinsic limitations and technical shortcomings, making its clinical use challenging. We used a multimodal intraoperative imaging protocol to update neuronavigation, based on the combination of intraoperative Ultrasound (i-US) and intraoperative Computed Tomography (i-CT) integrated with 5-ALA fluorescence and neuromonitoring-guided resection. METHODS This is a pilot study on 52 patients (29 men), including four children, with a mean age of 57.67 years, suffering from brain low- (N.=10) or high-grade (N.=34) glioma or metastasis (N.=8), prospectively and consecutively enrolled. They underwent 5-ALA fluorescence-guided microsurgical tumor resection and neuromonitoring was used in cases of lesions located in eloquent areas, according to preoperative clinical and neuroradiological features. Navigated B-mode ultrasound acquisition was carried out after dural opening to identify the lesion. After tumor resection, i-US was used to identify residual tumor. Following further tumor resection or in cases of unclear US images, post-contrast i-CT was performed to detect and localize small tumor remnants and to allow further correction for brain shift. A final i-US check was performed to verify the completeness of resection. Clinical evaluation was based on comparison of pre- and postoperative Karnofsky Performance Score (KPS) and assessment of overall survival (OS) and progression-free survival (PFS). Extent of tumor resection (EOTR) was evaluated by volumetric postoperative Magnetic Resonance performed within 48 h after surgery. RESULTS Forty-one of the 52 (78.8%) patients were alive and still under follow-up in December 2017. 5-ALA was strongly or vaguely positive in 45 cases (86.5%). Seven lesions (four low-grade glioma, one high-grade glioma, and two metastases) were not fluorescent. i-US visualized residual tumor after resection of all fluorescent or pathological tissue in 22 cases (42.3%). After i-US guided resection, i-CT documented the presence of further residual tumor in 11 cases (21.1%). Mean EOTR was 98.79% in the low-grade gliomas group, 99.84% in the high-grade gliomas group and 100% in the metastases group. KPS changed from 77.88, preoperatively, to 72.5, postoperatively. At the last follow-up, mean KPS was 84.23. CONCLUSIONS The combination of different intraoperative imaging modalities may increase brain tumor safety and extent of resection. In particular, i-US seems to be highly sensitive to detect residual tumors, but it may generate false positives due to artifacts. Conversely, i-CT is more specific to localize remnants, allowing a more reliable updating of navigation data.
Collapse
Affiliation(s)
- Giuseppe M Barbagallo
- Department of Neurological Surgery, Policlinico "G. Rodolico" University Hospital, Catania, Italy -
- Interdisciplinary Research Center on Brain Tumors Diagnosis and Treatment, University of Catania, Catania, Italy -
| | - Massimiliano Maione
- Department of Neurological Surgery, Policlinico "G. Rodolico" University Hospital, Catania, Italy
| | - Simone Peschillo
- Department of Neurological Surgery, Policlinico "G. Rodolico" University Hospital, Catania, Italy
- Interdisciplinary Research Center on Brain Tumors Diagnosis and Treatment, University of Catania, Catania, Italy
| | - Francesco Signorelli
- Department of Neurosurgery, Policlinico di Bari University Hospital, Bari, Italy
| | - Massimiliano Visocchi
- Institute of Neurosurgery, Sacred Heart Catholic University, Rome, Italy
- Department of Radiodiagnostics and Oncological Radiotherapy, Policlinico Vittorio Emanuele University Hospital, Catania, Italy
| | - Giuseppe Sortino
- Interdisciplinary Research Center on Brain Tumors Diagnosis and Treatment, University of Catania, Catania, Italy
| | - Giuseppa Fiumanò
- Interdisciplinary Research Center on Brain Tumors Diagnosis and Treatment, University of Catania, Catania, Italy
| | - Francesco Certo
- Department of Neurological Surgery, Policlinico "G. Rodolico" University Hospital, Catania, Italy
- Interdisciplinary Research Center on Brain Tumors Diagnosis and Treatment, University of Catania, Catania, Italy
| |
Collapse
|
3
|
Altieri R, Certo F, Pacella D, Cammarata G, Garozzo M, Broggi G, Caltabiano R, Magro G, Russo G, Cosentino S, Ippolito M, Barbagallo G. Metabolic delineation of IDH1 wild-type glioblastoma surgical anatomy: how to plan the tumor extent of resection. J Neurooncol 2023; 162:417-423. [PMID: 37039952 DOI: 10.1007/s11060-023-04305-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2023] [Accepted: 03/31/2023] [Indexed: 04/12/2023]
Abstract
PURPOSE Magnetic resonance imaging (MRI) is the current standard for preoperative planning of glioblastoma (GBM) surgery. However, recent data on the use of 11 C-methionine positron emission tomography (11[C]-MET PET) suggest its role in providing additional information beyond MRI. The purpose of this study is to establish if there is a correlation between anatomical and metabolic data. METHODS We retrieved all GBM cases treated from 2014 to January 2021. Preoperative MRI (Enhancing Nodule -EN-, FLAIR and Total Tumor Volume -TTV-), PET volumes and histological samples obtained from the different tumor regions were evaluated to analyze potential correlations between anatomical, metabolic and pathological data. RESULTS 150 patients underwent surgery for GBM and 49 of these were also studied preoperatively with 11[C]-MET PET; PET volume was evaluated in 47 patients. In 33 patients (70.21%) preoperative 11[C]-MET PET volume > preoperative EN volume and in 11 (23.4%) preoperative 11[C]-MET PET volume > preoperative TTV. We found a significant correlation between preoperative TTVs and PET volumes (p = 0.016) as well as between preoperative EN volumes and PET volumes (p = < 0.001). Histologically, 109 samples were evaluated. ENs samples exhibited the conventional GBM morphology while samples from the FLAIR regions showed white matter tissue, with focal to diffuse tumor cells infiltration and areas of reactive astrogliosis. CONCLUSION We submit that 11[C]-MET PET volume generally overcome EN. The presence of neoplastic cells confirm these metabolic data. It should be considered in the surgical planning to achieve a Supra Total Resection (SupTR).
Collapse
Affiliation(s)
- Roberto Altieri
- Department of Neurological Surgery, Policlinico "G. Rodolico-S. Marco" University Hospital, Catania, Italy.
- Interdisciplinary Research Center on Brain Tumors Diagnosis and Treatment, University of Catania, Catania, Italy.
| | - Francesco Certo
- Department of Neurological Surgery, Policlinico "G. Rodolico-S. Marco" University Hospital, Catania, Italy
- Interdisciplinary Research Center on Brain Tumors Diagnosis and Treatment, University of Catania, Catania, Italy
| | - Daniela Pacella
- Department of Public Health, University of Naples Federico II, Naples, Italy
| | - Giacomo Cammarata
- Department of Neurological Surgery, Policlinico "G. Rodolico-S. Marco" University Hospital, Catania, Italy
| | - Marco Garozzo
- Department of Neurological Surgery, Policlinico "G. Rodolico-S. Marco" University Hospital, Catania, Italy
| | - Giuseppe Broggi
- Department of Medical and Surgical Sciences and Advanced Technologies "G. F. Ingrassia", Anatomic Pathology, University of Catania, Catania, Italy
| | - Rosario Caltabiano
- Department of Medical and Surgical Sciences and Advanced Technologies "G. F. Ingrassia", Anatomic Pathology, University of Catania, Catania, Italy
| | - Gaetano Magro
- Department of Medical and Surgical Sciences and Advanced Technologies "G. F. Ingrassia", Anatomic Pathology, University of Catania, Catania, Italy
| | - Giorgio Russo
- Institute of Molecular Bioimaging and Physiology, National Research Council (CNR), Cefalù, PA, Italy
| | | | - Massimo Ippolito
- Nuclear Medicine Department, Cannizzaro Hospital, Catania, Italy
| | - Giuseppe Barbagallo
- Department of Neurological Surgery, Policlinico "G. Rodolico-S. Marco" University Hospital, Catania, Italy
- Interdisciplinary Research Center on Brain Tumors Diagnosis and Treatment, University of Catania, Catania, Italy
| |
Collapse
|
4
|
Ius T, Sabatino G, Panciani PP, Fontanella MM, Rudà R, Castellano A, Barbagallo GMV, Belotti F, Boccaletti R, Catapano G, Costantino G, Della Puppa A, Di Meco F, Gagliardi F, Garbossa D, Germanò AF, Iacoangeli M, Mortini P, Olivi A, Pessina F, Pignotti F, Pinna G, Raco A, Sala F, Signorelli F, Sarubbo S, Skrap M, Spena G, Somma T, Sturiale C, Angileri FF, Esposito V. Surgical management of Glioma Grade 4: technical update from the neuro-oncology section of the Italian Society of Neurosurgery (SINch®): a systematic review. J Neurooncol 2023; 162:267-293. [PMID: 36961622 PMCID: PMC10167129 DOI: 10.1007/s11060-023-04274-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Accepted: 02/20/2023] [Indexed: 03/25/2023]
Abstract
PURPOSE The extent of resection (EOR) is an independent prognostic factor for overall survival (OS) in adult patients with Glioma Grade 4 (GG4). The aim of the neuro-oncology section of the Italian Society of Neurosurgery (SINch®) was to provide a general overview of the current trends and technical tools to reach this goal. METHODS A systematic review was performed. The results were divided and ordered, by an expert team of surgeons, to assess the Class of Evidence (CE) and Strength of Recommendation (SR) of perioperative drugs management, imaging, surgery, intraoperative imaging, estimation of EOR, surgery at tumor progression and surgery in elderly patients. RESULTS A total of 352 studies were identified, including 299 retrospective studies and 53 reviews/meta-analysis. The use of Dexamethasone and the avoidance of prophylaxis with anti-seizure medications reached a CE I and SR A. A preoperative imaging standard protocol was defined with CE II and SR B and usefulness of an early postoperative MRI, with CE II and SR B. The EOR was defined the strongest independent risk factor for both OS and tumor recurrence with CE II and SR B. For intraoperative imaging only the use of 5-ALA reached a CE II and SR B. The estimation of EOR was established to be fundamental in planning postoperative adjuvant treatments with CE II and SR B and the stereotactic image-guided brain biopsy to be the procedure of choice when an extensive surgical resection is not feasible (CE II and SR B). CONCLUSIONS A growing number of evidences evidence support the role of maximal safe resection as primary OS predictor in GG4 patients. The ongoing development of intraoperative techniques for a precise real-time identification of peritumoral functional pathways enables surgeons to maximize EOR minimizing the post-operative morbidity.
Collapse
Affiliation(s)
- Tamara Ius
- Division of Neurosurgery, Head-Neck and NeuroScience Department, University Hospital of Udine, Udine, Italy
| | - Giovanni Sabatino
- Institute of Neurosurgery, Fondazione Policlinico Gemelli, Catholic University, Rome, Italy
- Unit of Neurosurgery, Mater Olbia Hospital, Olbia, Italy
| | - Pier Paolo Panciani
- Division of Neurosurgery, Department of Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy.
| | - Marco Maria Fontanella
- Department of Neuro-Oncology, University of Turin and City of Health and Science Hospital, 10094, Torino, Italy
| | - Roberta Rudà
- Department of Neuro-Oncology, University of Turin and City of Health and Science Hospital, 10094, Torino, Italy
- Neurology Unit, Hospital of Castelfranco Veneto, 31033, Castelfranco Veneto, Italy
| | - Antonella Castellano
- Department of Neuroradiology, San Raffaele Scientific Institute, Vita-Salute University, Milan, Italy
| | - Giuseppe Maria Vincenzo Barbagallo
- Department of Medical and Surgical Sciences and Advanced Technologies (G.F. Ingrassia), Neurological Surgery, Policlinico "G. Rodolico - San Marco" University Hospital, University of Catania, Catania, Italy
- Interdisciplinary Research Center On Brain Tumors Diagnosis and Treatment, University of Catania, Catania, Italy
| | - Francesco Belotti
- Division of Neurosurgery, Department of Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
| | | | - Giuseppe Catapano
- Division of Neurosurgery, Department of Neurological Sciences, Ospedale del Mare, Naples, Italy
| | | | - Alessandro Della Puppa
- Neurosurgical Clinical Department of Neuroscience, Psychology, Pharmacology and Child Health, Careggi Hospital, University of Florence, Florence, Italy
| | - Francesco Di Meco
- Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
- Johns Hopkins Medical School, Baltimore, MD, USA
| | - Filippo Gagliardi
- Department of Neurosurgery and Gamma Knife Radiosurgery, San Raffaele Scientific Institute, Vita-Salute University, Milan, Italy
| | - Diego Garbossa
- Department of Neuroscience "Rita Levi Montalcini," Neurosurgery Unit, University of Turin, Torino, Italy
| | | | - Maurizio Iacoangeli
- Department of Neurosurgery, Università Politecnica Delle Marche, Azienda Ospedali Riuniti, Ancona, Italy
| | - Pietro Mortini
- Department of Neurosurgery and Gamma Knife Radiosurgery, San Raffaele Scientific Institute, Vita-Salute University, Milan, Italy
| | | | - Federico Pessina
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, 20090, Milan, Italy
- Neurosurgery Department, IRCCS Humanitas Research Hospital, Via Manzoni 56, 20089, Milan, Italy
| | - Fabrizio Pignotti
- Institute of Neurosurgery, Fondazione Policlinico Gemelli, Catholic University, Rome, Italy
- Unit of Neurosurgery, Mater Olbia Hospital, Olbia, Italy
| | - Giampietro Pinna
- Unit of Neurosurgery, Department of Neurosciences, Hospital Trust of Verona, 37134, Verona, Italy
| | - Antonino Raco
- Division of Neurosurgery, Department of NESMOS, AOU Sant'Andrea, Sapienza University, Rome, Italy
| | - Francesco Sala
- Department of Neurosciences, Biomedicines and Movement Sciences, Institute of Neurosurgery, University of Verona, 37134, Verona, Italy
| | - Francesco Signorelli
- Department of Basic Medical Sciences, Neuroscience and Sense Organs, Neurosurgery Unit, University "Aldo Moro", 70124, Bari, Italy
| | - Silvio Sarubbo
- Department of Neurosurgery, Santa Chiara Hospital, Azienda Provinciale Per I Servizi Sanitari (APSS), Trento, Italy
| | - Miran Skrap
- Division of Neurosurgery, Head-Neck and NeuroScience Department, University Hospital of Udine, Udine, Italy
| | | | - Teresa Somma
- Division of Neurosurgery, Department of Neurosciences, Reproductive and Odontostomatological Sciences, Università Degli Studi Di Napoli Federico II, Naples, Italy
| | | | | | - Vincenzo Esposito
- Department of Neurosurgery "Giampaolo Cantore"-IRCSS Neuromed, Pozzilli, Italy
- Department of Human, Neurosciences-"Sapienza" University of Rome, Rome, Italy
| |
Collapse
|
5
|
Certo F, Altieri R, Crimi S, Gurrera G, Cammarata G, Visocchi M, Bianchi A, Barbagallo GMV. Image-Guided Surgery in Complex Skull Base and Facial Fractures: Initial Experience on the Role of Intra-Operative Computer Tomography. ACTA NEUROCHIRURGICA. SUPPLEMENT 2023; 135:61-67. [PMID: 38153450 DOI: 10.1007/978-3-031-36084-8_11] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/29/2023]
Abstract
Surgery of fractures involving the skull base and the facial skeleton often presents challenges that should be addressed to prevent secondary brain injuries (i.e., cerebro-spinal fluid leak), preserve visual functioning, and guarantee a good esthetic result. Complex craniofacial reconstruction can be aided by navigation and pre-operative planning. In recent years, computerized planning of surgical reconstruction drastically increased the safety and efficacy of surgery, but the impact of intraoperative high quality image devices such as an intraoperative computed tomography (CT) scan has not been investigated yet. This case-control study reports the institutional preliminary experience of using intraoperative CT scans in the surgical management of complex cranio-facial fractures. The results in terms of accuracy of bony reconstruction and neurological or surgical complications have been analyzed in 12 consecutive patients treated with (6 cases) or without (6 cases) i-CT. Comparative analysis demonstrated a greater accuracy of reconstruction in patients treated with the assistance of i-CT. Intraoperative CT is a useful tool with a promising role in a multidisciplinary surgical approach to complex cranio-facial surgery.
Collapse
Affiliation(s)
- Francesco Certo
- Department of Medical and Surgical Sciences and Advanced Technologies (G.F. Ingrassia), Neurological Surgery, Policlinico "G. Rodolico-San Marco" University Hospital, University of Catania, Catania, Italy
- Department of Neurological Surgery, Policlinico "G. Rodolico" University Hospital, Catania, Italy
| | - Roberto Altieri
- Department of Medical and Surgical Sciences and Advanced Technologies (G.F. Ingrassia), Neurological Surgery, Policlinico "G. Rodolico-San Marco" University Hospital, University of Catania, Catania, Italy
| | - Salvatore Crimi
- Department of General Surgery, Section of Maxillo Facial Surgery Policlinico "G. Rodolico-San Marco" University Hospital, University of Catania, Catania, Italy
| | - Giorgio Gurrera
- Department of General Surgery, Section of Maxillo Facial Surgery Policlinico "G. Rodolico-San Marco" University Hospital, University of Catania, Catania, Italy
| | - Giacomo Cammarata
- Department of Medical and Surgical Sciences and Advanced Technologies (G.F. Ingrassia), Neurological Surgery, Policlinico "G. Rodolico-San Marco" University Hospital, University of Catania, Catania, Italy
| | | | - Alberto Bianchi
- Department of General Surgery, Section of Maxillo Facial Surgery Policlinico "G. Rodolico-San Marco" University Hospital, University of Catania, Catania, Italy
| | - Giuseppe M V Barbagallo
- Department of Medical and Surgical Sciences and Advanced Technologies (G.F. Ingrassia), Neurological Surgery, Policlinico "G. Rodolico-San Marco" University Hospital, University of Catania, Catania, Italy
| |
Collapse
|
6
|
Certo F, Altieri R, Grasso G, Barbagallo GMV. Role of i-CT, i-US, and Neuromonitoring in Surgical Management of Brain Cavernous Malformations and Arteriovenous Malformations: A Case Series. World Neurosurg 2022; 159:402-408. [PMID: 35255639 DOI: 10.1016/j.wneu.2021.12.078] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2021] [Revised: 12/19/2021] [Accepted: 12/20/2021] [Indexed: 11/18/2022]
Abstract
OBJECTIVE We retrospectively reviewed the institutional experience in patients who underwent microsurgical resection of cavernous malformations (CMs) or arteriovenous malformations (AVMs) using a multimodal intraoperative protocol including neuronavigation, intraoperative ultrasound (i-US), computed tomography (i-CT), and neuromonitoring. METHODS Twenty-four patients (14 male), with a mean age of 47.5 years (range 27-73), have been included: 20 of them suffered from CMs and 4 suffered from AVMs. Neuromonitoring was used in 18 cases, when lesions were located in eloquent areas; 2 patients underwent awake craniotomy. First, an i-CT scan with and without contrast was acquired after patient positioning. Navigated B-mode ultrasound acquisition was carried out after dural opening to identify the lesion (CMs or AVMs nidus). Following identification and resection of vascular lesions, postcontrast i-CT (or CT-angio) was performed to detect and localize any small or calcified remnant (in cases of CMs) or residual vessels feeding the nidus (in cases of AVMs). RESULTS In 5 cases of CMs and in 1 case of AVM, i-CT identified small residual lesions. In these cases, new i-CT images were uploaded into the navigation system and used for further resection. i-US was useful before starting transsulcal or transcortical approach to identify the lesions and guide the trajectory of the approach. However, several artifacts were observed during subsequent steps of dissection, making image interpretation difficult. CONCLUSIONS The combination of different intraoperative real-time imaging modalities (i-CT and i-US), coupled with neuromonitoring, in the surgical management of vascular lesions, particularly if located in eloquent areas, has a positive impact on clinical outcome.
Collapse
Affiliation(s)
- Francesco Certo
- Department of Medical, Surgical Sciences and Advanced Technologies "G. F. Ingrassia," Neurological Surgery, Policlinico "Rodolico-San Marco" University Hospital, University of Catania, Catania, Italy.
| | - Roberto Altieri
- Department of Medical, Surgical Sciences and Advanced Technologies "G. F. Ingrassia," Neurological Surgery, Policlinico "Rodolico-San Marco" University Hospital, University of Catania, Catania, Italy
| | - Giovanni Grasso
- Department of Biomedicine, Neurosciences and Advanced Diagnostics (BiND), Neurosurgical Unit, Surgical Neuro-oncology Section, University of Palermo, Palermo, Italy
| | - Giuseppe M V Barbagallo
- Department of Medical, Surgical Sciences and Advanced Technologies "G. F. Ingrassia," Neurological Surgery, Policlinico "Rodolico-San Marco" University Hospital, University of Catania, Catania, Italy
| |
Collapse
|
7
|
Intraoperative 5-ALA fluorescence-guided resection of high-grade glioma leads to greater extent of resection with better outcomes: a systematic review. J Neurooncol 2022; 156:233-256. [PMID: 34989964 DOI: 10.1007/s11060-021-03901-9] [Citation(s) in RCA: 32] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Accepted: 11/12/2021] [Indexed: 12/13/2022]
Abstract
IMPORTANCE High-grade gliomas (HGG) are the most aggressive and common malignant brain tumors in adults. They have a dismally fatal prognosis. Even if gross total resection of the enhancing tumor is achieved, inevitably, invading tumor cells that are indistinguishable to the un-aided eye are left behind, which eventually leads to tumor recurrence. 5-aminolevulinic acid (5-ALA) is an increasingly utilized intraoperative fluorescent imaging agent for patients with HGG. It enhances visualization of HGG tissue. Despite early promising randomized clinical trial data suggesting a survival benefit for 5-ALA-guided surgery, the growing body of literature must be analyzed to confirm efficacy on patient outcomes. OBJECTIVE To perform a systematic review of the literature to evaluate whether there is a beneficial effect upon survival and extent of resection due to the utilization of 5-ALA in HGG surgery. EVIDENCE REVIEW Literature regarding 5-ALA usage in HGG surgery was reviewed according to the PRISMA guidelines. Two databases, PubMed and SCOPUS, were searched for assorted combinations of the keywords "5-ALA," "high-grade glioma," "5-aminolevulinic acid," and "resection" in July 2020 for case reports and retrospective, prospective, and randomized clinical trials assessing and analyzing 5-ALA intraoperative use in patients with HGG. Entailed studies on PubMed and SCOPUS were found for screening using a snowball search technique upon the initially searched papers. Systematic reviews and meta-analyses were excluded from our PRISMA table. FINDINGS 3756 previously published studies were screened, 536 of which were further evaluated, and ultimately 45 were included in our systematic review. There were no date restrictions on the screened publications. Our literature search was finalized on July 16, 2020. We found an observed increase in the overall survival (OS) and progression-free survival (PFS) of the 5-ALA group compared to the white light group, as well as an observed increase in the OS and PFS of complete resections compared to incomplete resections. Of the studies that directly compared the use of 5-ALA to white light (13 of the total analyzed 45, or 28.9%), 5-ALA lead to a better PFS and OS in 88.4 and 67.5% of patients, respectively. When the studies that reported postoperative neurologic outcomes of surgeries using 5-ALA vs. white light were analyzed, 42.2% of subjects demonstrated 5-ALA use was associated with less post-op neurological deficits, whereas 34.5% demonstrated no difference between 5-ALA and without. 23.3% of studies showed that intraoperative 5-ALA guided surgeries lead to more post-op neurological deficits. CONCLUSIONS AND RELEVANCE Utilization of 5-ALA was found to be associated with a greater extent of resection in HGG surgeries, as well as longer OS and PFS. Postop neurologic deficit rates were mixed and inconclusive when comparing 5-ALA groups to white light groups. 5-ALA is a useful surgical adjunct for resection of HGG when patient safety is preserved.
Collapse
|
8
|
Broggi G, Certo F, Altieri R, Caltabiano R, Gessi M, Barbagallo GMV. A "polymorphous low-grade neuroepithelial tumor of the young (PLNTY)" diagnosed in an adult. Report of a case and review of the literature. Surg Neurol Int 2021; 12:470. [PMID: 34621585 PMCID: PMC8492409 DOI: 10.25259/sni_500_2021] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2021] [Accepted: 08/25/2021] [Indexed: 12/17/2022] Open
Abstract
Background: Polymorphous low-grade neuroepithelial tumor of the young (PLNTY) is a rare neuropathological entity, recently introduced in neuro-oncology. These tumors, histologically similar to oligodendrogliomas, cause epilepsy, occurring in children and young adults. Only few cases of PLNTY have been described in literature and all reported cases invariably focused on the onset of these tumors in children and young adults. Case Description: We report the case of a 50-year-old woman suffering from epilepsy since the 1st year of her life. Computed tomography scan and magnetic resonance imaging of the brain documented the presence of a calcified mass involving left temporal lobe. The tumor was surgically excised and the histological examination showed a hypocellular and massively calcified neoplasm with morphological and immunohistochemical features consistent with the diagnosis of “PLNTY.” Conclusion: A review of the literature revealed that there are 31 cases of PLNTY reported in literature, most of which are children or young adults. The present case represents the second PLNTY diagnosed in a middle-aged adult to the best of our knowledge, suggesting that PLNTY should always be included in the differential diagnosis of low-grade brain tumors, also in adult patients.
Collapse
Affiliation(s)
- Giuseppe Broggi
- Department of Medical, Surgical Sciences and Advanced Technologies "G.F. Ingrassia", Anatomic Pathology, University of Catania
| | - Francesco Certo
- Department of Medical, Surgical Sciences and Advanced Technologies "G.F. Ingrassia", Neurological Surgery, Policlinico "Rodolico-San Marco" University Hospital, University of Catania, 95123 Catania
| | - Roberto Altieri
- Department of Medical, Surgical Sciences and Advanced Technologies "G.F. Ingrassia", Neurological Surgery, Policlinico "Rodolico-San Marco" University Hospital, University of Catania, 95123 Catania
| | - Rosario Caltabiano
- Department of Medical, Surgical Sciences and Advanced Technologies "G.F. Ingrassia", Anatomic Pathology, University of Catania
| | - Marco Gessi
- Neuropathology Unit, Catholic University, Fondazione Policlinico Universitario "A. Gemelli" IRCSS, Rome, Italy
| | - Giuseppe Maria Vincenzo Barbagallo
- Department of Medical, Surgical Sciences and Advanced Technologies "G.F. Ingrassia", Neurological Surgery, Policlinico "Rodolico-San Marco" University Hospital, University of Catania, 95123 Catania
| |
Collapse
|
9
|
Saß B, Pojskic M, Zivkovic D, Carl B, Nimsky C, Bopp MHA. Utilizing Intraoperative Navigated 3D Color Doppler Ultrasound in Glioma Surgery. Front Oncol 2021; 11:656020. [PMID: 34490080 PMCID: PMC8416533 DOI: 10.3389/fonc.2021.656020] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2021] [Accepted: 07/23/2021] [Indexed: 01/23/2023] Open
Abstract
Background In glioma surgery, the patient’s outcome is dramatically influenced by the extent of resection and residual tumor volume. To facilitate safe resection, neuronavigational systems are routinely used. However, due to brain shift, accuracy decreases with the course of the surgery. Intraoperative ultrasound has proved to provide excellent live imaging, which may be integrated into the navigational procedure. Here we describe the visualization of vascular landmarks and their shift during tumor resection using intraoperative navigated 3D color Doppler ultrasound (3D iUS color Doppler). Methods Six patients suffering from glial tumors located in the temporal lobe were included in this study. Intraoperative computed tomography was used for registration. Datasets of 3D iUS color Doppler were generated before dural opening and after tumor resection, and the vascular tree was segmented manually. In each dataset, one to four landmarks were identified, compared to the preoperative MRI, and the Euclidean distance was calculated. Results Pre-resectional mean Euclidean distance of the marked points was 4.1 ± 1.3 mm (mean ± SD), ranging from 2.6 to 6.0 mm. Post-resectional mean Euclidean distance was 4.7. ± 1.0 mm, ranging from 2.9 to 6.0 mm. Conclusion 3D iUS color Doppler allows estimation of brain shift intraoperatively, thus increasing patient safety. Future implementation of the reconstructed vessel tree into the navigational setup might allow navigational updating with further consecutive increasement of accuracy.
Collapse
Affiliation(s)
- Benjamin Saß
- Department of Neurosurgery, University of Marburg, Marburg, Germany
| | - Mirza Pojskic
- Department of Neurosurgery, University of Marburg, Marburg, Germany
| | - Darko Zivkovic
- Department of Neurosurgery, University of Marburg, Marburg, Germany
| | - Barbara Carl
- Department of Neurosurgery, University of Marburg, Marburg, Germany.,Department of Neurosurgery, Helios Dr. Horst Schmidt Kliniken, Wiesbaden, Germany
| | - Christopher Nimsky
- Department of Neurosurgery, University of Marburg, Marburg, Germany.,Center for Mind, Brain and Behavior (CMBB), Marburg, Germany
| | - Miriam H A Bopp
- Department of Neurosurgery, University of Marburg, Marburg, Germany.,Center for Mind, Brain and Behavior (CMBB), Marburg, Germany
| |
Collapse
|
10
|
Certo F, Altieri R, Maione M, Schonauer C, Sortino G, Fiumanò G, Tirrò E, Massimino M, Broggi G, Vigneri P, Magro G, Visocchi M, Barbagallo GMV. FLAIRectomy in Supramarginal Resection of Glioblastoma Correlates With Clinical Outcome and Survival Analysis: A Prospective, Single Institution, Case Series. Oper Neurosurg (Hagerstown) 2021; 20:151-163. [PMID: 33035343 DOI: 10.1093/ons/opaa293] [Citation(s) in RCA: 41] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2020] [Accepted: 07/02/2020] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Extent of tumor resection (EOTR) in glioblastoma surgery plays an important role in improving survival. OBJECTIVE To analyze the efficacy, safety and reliability of fluid-attenuated inversion-recovery (FLAIR) magnetic resonance (MR) images used to guide glioblastoma resection (FLAIRectomy) and to volumetrically measure postoperative EOTR, which was correlated with clinical outcome and survival. METHODS A total of 68 glioblastoma patients (29 males, mean age 65.8) were prospectively enrolled. Hyperintense areas on FLAIR images, surrounding gadolinium-enhancing tissue on T1-weighted MR images, were screened for signal changes suggesting tumor infiltration and evaluated for supramaximal resection. The surgical protocol included 5-aminolevulinic acid (5-ALA) fluorescence, neuromonitoring, and intraoperative imaging tools. 5-ALA fluorescence intensity was analyzed and matched with the different sites on navigated MR, both on postcontrast T1-weighted and FLAIR images. Volumetric evaluation of EOTR on T1-weighted and FLAIR sequences was compared. RESULTS FLAIR MR volumetric evaluation documented larger tumor volume than that assessed on contrast-enhancing T1 MR (72.6 vs 54.9 cc); residual tumor was seen in 43 patients; postcontrast T1 MR volumetric analysis showed complete resection in 64 cases. O6-methylguanine-DNA methyltransferase promoter was methylated in 8/68 (11.7%) cases; wild type Isocytrate Dehydrogenase-1 (IDH-1) was found in 66/68 patients. Progression free survival and overall survival (PFS and OS) were 17.43 and 25.11 mo, respectively. Multiple regression analysis showed a significant correlation between EOTR based on FLAIR, PFS (R2 = 0.46), and OS (R2 = 0.68). CONCLUSION EOTR based on FLAIR and 5-ALA fluorescence is feasible. Safety of resection relies on the use of neuromonitoring and intraoperative multimodal imaging tools. FLAIR-based EOTR appears to be a stronger survival predictor compared to gadolinium-enhancing, T1-based resection.
Collapse
Affiliation(s)
- Francesco Certo
- Department of Medical and Surgical Sciences and Advanced Technologies (G.F. Ingrassia), Neurological Surgery, Policlinico ``G. Rodolico - San Marco'' University Hospital, University of Catania, Italy.,Interdisciplinary Research Center on Brain Tumors Diagnosis and Treatment, University of Catania, Via S. Sofia, Catania, Italy
| | - Roberto Altieri
- Department of Medical and Surgical Sciences and Advanced Technologies (G.F. Ingrassia), Neurological Surgery, Policlinico ``G. Rodolico - San Marco'' University Hospital, University of Catania, Italy
| | - Massimiliano Maione
- Department of Medical and Surgical Sciences and Advanced Technologies (G.F. Ingrassia), Neurological Surgery, Policlinico ``G. Rodolico - San Marco'' University Hospital, University of Catania, Italy
| | - Claudio Schonauer
- Department of Neurological Surgery, Santa Maria delle Grazie Hospital ASLNa2Nord, Via Domitiana, Naples, Italy
| | - Giuseppe Sortino
- Department of Radiodiagnostic and Oncological Radiotherapy, University Hospital Policlinico-Vittorio Emanuele, Via S. Sofia, Catania, Italy
| | - Giuseppa Fiumanò
- Department of Neurological Surgery, Santa Maria delle Grazie Hospital ASLNa2Nord, Via Domitiana, Naples, Italy
| | - Elena Tirrò
- Department of Clinical and Experimental Medicine, Center of Experimental Oncology and Hematology, University Hospital Policlinico-Vittorio Emanuele, Via S. Sofia, Catania, Italy
| | - Michele Massimino
- Department of Clinical and Experimental Medicine, Center of Experimental Oncology and Hematology, University Hospital Policlinico-Vittorio Emanuele, Via S. Sofia, Catania, Italy
| | - Giuseppe Broggi
- Department of Medical and Surgical Sciences and Advanced Technologies (G.F. Ingrassia), Anatomic Pathology, Policlinico ``G. Rodolico - San Marco'' University Hospital, University of Catania, Italy
| | - Paolo Vigneri
- Department of Clinical and Experimental Medicine, Center of Experimental Oncology and Hematology, University Hospital Policlinico-Vittorio Emanuele, Via S. Sofia, Catania, Italy
| | - Gaetano Magro
- Department of Medical and Surgical Sciences and Advanced Technologies (G.F. Ingrassia), Anatomic Pathology, Policlinico ``G. Rodolico - San Marco'' University Hospital, University of Catania, Italy
| | - Massimiliano Visocchi
- Institute of Neurosurgery, Catholic University, Via della Pineta Sacchetti, Rome, Italy
| | - Giuseppe M V Barbagallo
- Department of Medical and Surgical Sciences and Advanced Technologies (G.F. Ingrassia), Neurological Surgery, Policlinico ``G. Rodolico - San Marco'' University Hospital, University of Catania, Italy.,Interdisciplinary Research Center on Brain Tumors Diagnosis and Treatment, University of Catania, Via S. Sofia, Catania, Italy
| |
Collapse
|
11
|
Barbagallo GMV, Altieri R, Garozzo M, Maione M, Di Gregorio S, Visocchi M, Peschillo S, Dolce P, Certo F. High Grade Glioma Treatment in Elderly People: Is It Different Than in Younger Patients? Analysis of Surgical Management Guided by an Intraoperative Multimodal Approach and Its Impact on Clinical Outcome. Front Oncol 2021; 10:631255. [PMID: 33718122 PMCID: PMC7943843 DOI: 10.3389/fonc.2020.631255] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2020] [Accepted: 12/30/2020] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE Age is considered a negative prognostic factor for High Grade Gliomas (HGGs) and many neurosurgeons remain skeptical about the benefits of aggressive treatment. New surgical and technological improvements may allow extended safe resection, with lower level of post-operative complications. This opportunity opens the unsolved question about the most appropriate HGG treatment in elderly patients. The aim of this study is to analyze if HGG maximal safe resection guided by an intraoperative multimodal imaging protocol coupled with neuromonitoring is associated with differences in outcome in elderly patients versus younger ones. METHODS We reviewed 100 patients, 53 (53%) males and 47 (47%) females, with median (IQR) age of 64 (57; 72) years. Eight patients were diagnosed with Anaplastic Astrocytoma (AA), 92 with Glioblastoma (GBM). Surgery was aimed to achieve safe maximal resection. An intraoperative multimodal imaging protocol, including neuronavigation, neurophysiological monitoring, 5-ALA fluorescence, 11C MET-PET, navigated i-US system and i-CT, was used, and its impact on EOTR and clinical outcome in elderly patients was analyzed. We divided patients in two groups according to their age: <65 and >65 years, and surgical and clinical results (EOTR, post-operative KPS, OS and PFS) were compared. Yet, to better understand age-related differences, the same patient cohort was also divided into <70 and >70 years and all the above data reanalyzed. RESULTS In the first cohort division, we did not found KPS difference over time and survival analysis did not show significant difference between the two groups (p = 0.36 for OS and p = 0.49 for PFS). Same results were obtained increasing the age cut-off for age up to 70 years (p = 0.52 for OS and p = 0.92 for PFS). CONCLUSIONS Our data demonstrate that there is not statistically significant difference in post-operative EOTR, KPS, OS, and PFS between younger and elderly patients treated with extensive tumor resection aided by a intraoperative multimodal protocol.
Collapse
Affiliation(s)
- Giuseppe Maria Vincenzo Barbagallo
- Department of Neurological Surgery, Policlinico "G. Rodolico" University Hospital, Catania, Italy
- Interdisciplinary Research Center on Brain Tumors Diagnosis and Treatment, University of Catania, Catania, Italy
| | - Roberto Altieri
- Department of Neurological Surgery, Policlinico "G. Rodolico" University Hospital, Catania, Italy
- Interdisciplinary Research Center on Brain Tumors Diagnosis and Treatment, University of Catania, Catania, Italy
- Department of Neuroscience, University of Turin, Turin, Italy
| | - Marco Garozzo
- Department of Neurological Surgery, Policlinico "G. Rodolico" University Hospital, Catania, Italy
| | - Massimiliano Maione
- Department of Neurological Surgery, Policlinico "G. Rodolico" University Hospital, Catania, Italy
| | - Stefania Di Gregorio
- Department of Neurological Surgery, Policlinico "G. Rodolico" University Hospital, Catania, Italy
| | | | - Simone Peschillo
- Department of Neurological Surgery, Policlinico "G. Rodolico" University Hospital, Catania, Italy
| | - Pasquale Dolce
- Department of Public Health, University of Naples Federico II, Naples, Italy
| | - Francesco Certo
- Department of Neurological Surgery, Policlinico "G. Rodolico" University Hospital, Catania, Italy
- Interdisciplinary Research Center on Brain Tumors Diagnosis and Treatment, University of Catania, Catania, Italy
| |
Collapse
|
12
|
Barbagallo GMV, Certo F, Di Gregorio S, Maione M, Garozzo M, Peschillo S, Altieri R. Recurrent high-grade glioma surgery: a multimodal intraoperative protocol to safely increase extent of tumor resection and analysis of its impact on patient outcome. Neurosurg Focus 2021; 50:E20. [PMID: 33386001 DOI: 10.3171/2020.10.focus20744] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2020] [Accepted: 10/28/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE No consensus exists on the best treatment for recurrent high-grade glioma (HGG), particularly in terms of surgical indications, and scant data are available on the integrated use of multiple technologies to overcome intraoperative limits and pitfalls related to artifacts secondary to previous surgery and radiotherapy. Here, the authors report on their experience with the integration of multiple intraoperative tools in recurrent HGG surgery, analyzing their pros and cons as well as their effectiveness in increasing the extent of tumor resection. In addition, they present a review of the relevant literature on this topic. METHODS The authors reviewed all cases in which recurrent HGG had been histologically diagnosed after a first surgery and the patient had undergone a second surgery involving neuronavigation with MRI, intraoperative CT (iCT), 11C-methionine-positron emission tomography (11C-MET-PET), 5-aminolevulinic acid (5-ALA) fluorescence, intraoperative neurophysiological monitoring (IONM), and intraoperative navigated ultrasound (iUS). All cases were classified according to tumor functional grade (1, noneloquent area; 2, near an eloquent area; 3, eloquent area). RESULTS Twenty patients with recurrent HGG were operated on using a multimodal protocol. The recurrent tumor functional grade was 1 in 4 patients, 2 in 8 patients, and 3 in the remaining 8 patients. In all patients but 2, 100% EOTR was obtained. Intraoperative 5-ALA fluorescence and navigated iUS showed low specificity and sensitivity. iCT detected tumor remnants in 3 cases. Postoperatively, 6 patients (30%) had worsening neurological conditions: 4 recovered within 90 days, 1 partially recovered, and 1 experienced a permanent deficit. The median Karnofsky Performance Status remained substantially unchanged over the follow-up period. The mean progression-free survival after the second surgery was 7.7 months (range 2-11 months). The mean overall survival was 25.4 months (range 10-52 months), excluding 2 long survivors. Two patients died within 60 days after surgery, and 3 patients were still under follow-up at the end of this study. CONCLUSIONS This is the first study reporting the integration of neuronavigation, 5-ALA fluorescence, iUS, iCT, 11C-MET-PET, and IOM during microsurgical resection of recurrent glioma. The authors believe that the proposed multimodal protocol is useful to increase the safety, effectiveness, and EOTR in patients with recurrent HGG and brain alterations secondary to radio- and chemotherapy.
Collapse
Affiliation(s)
- Giuseppe Maria Vincenzo Barbagallo
- 1Division of Neurosurgery, Department of Neurosciences, Policlinico "G. Rodolico-S. Marco," University Hospital, Catania.,2Multidisciplinary Research Center on Brain Tumors Diagnosis and Treatment, University of Catania; and
| | - Francesco Certo
- 1Division of Neurosurgery, Department of Neurosciences, Policlinico "G. Rodolico-S. Marco," University Hospital, Catania.,2Multidisciplinary Research Center on Brain Tumors Diagnosis and Treatment, University of Catania; and
| | - Stefania Di Gregorio
- 1Division of Neurosurgery, Department of Neurosciences, Policlinico "G. Rodolico-S. Marco," University Hospital, Catania
| | - Massimiliano Maione
- 1Division of Neurosurgery, Department of Neurosciences, Policlinico "G. Rodolico-S. Marco," University Hospital, Catania
| | - Marco Garozzo
- 1Division of Neurosurgery, Department of Neurosciences, Policlinico "G. Rodolico-S. Marco," University Hospital, Catania
| | - Simone Peschillo
- 1Division of Neurosurgery, Department of Neurosciences, Policlinico "G. Rodolico-S. Marco," University Hospital, Catania
| | - Roberto Altieri
- 1Division of Neurosurgery, Department of Neurosciences, Policlinico "G. Rodolico-S. Marco," University Hospital, Catania.,2Multidisciplinary Research Center on Brain Tumors Diagnosis and Treatment, University of Catania; and.,3Department of Neuroscience, University of Turin, Italy
| |
Collapse
|
13
|
Intraoperative CT and cone-beam CT imaging for minimally invasive evacuation of spontaneous intracerebral hemorrhage. Acta Neurochir (Wien) 2020; 162:3167-3177. [PMID: 32193726 PMCID: PMC7593312 DOI: 10.1007/s00701-020-04284-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2020] [Accepted: 03/04/2020] [Indexed: 01/25/2023]
Abstract
Background Minimally invasive surgery (MIS) for evacuation of spontaneous intracerebral hemorrhage (ICH) has shown promise but there remains a need for intraoperative performance assessment considering the wide range of evacuation effectiveness. In this feasibility study, we analyzed the benefit of intraoperative 3-dimensional imaging during navigated endoscopy-assisted ICH evacuation by mechanical clot fragmentation and aspiration. Methods 18 patients with superficial or deep supratentorial ICH underwent MIS for clot evacuation followed by intraoperative computerized tomography (iCT) or cone-beam CT (CBCT) imaging. Eligibility for MIS required (a) availability of intraoperative iCT or CBCT, (b) spontaneous lobar or deep ICH without vascular pathology, (c) a stable ICH volume (20–90 ml), (d) a reduced level of consciousness (GCS 5–14), and (e) a premorbid mRS ≤ 1. Demographic, clinical, and radiographic patient data were analyzed by two independent observers. Results Nine female and 9 male patients with a median age of 76 years (42–85) presented with an ICH score of 3 (1–4), GCS of 10 (5–14) and ICH volume of 54 ± 26 ml. Clot fragmentation and aspiration was feasible in all cases and intraoperative imaging determined an overall evacuation rate of 80 ± 19% (residual hematoma volume: 13 ± 17 ml; p < 0.0001 vs. Pre-OP). Based on the intraoperative imaging results, 1/3rd of all patients underwent an immediate re-aspiration attempt. No patient experienced hemorrhagic complications or required conversion to open craniotomy. However, routine postoperative CT imaging revealed early hematoma re-expansion with an adjusted evacuation rate of 59 ± 30% (residual hematoma volume: 26 ± 37 ml; p < 0.001 vs. Pre-OP). Conclusions Routine utilization of iCT or CBCT imaging in MIS for ICH permits direct surgical performance assessment and the chance for immediate re-aspiration, which may optimize targeting of an ideal residual hematoma volume and reduce secondary revision rates. Electronic supplementary material The online version of this article (10.1007/s00701-020-04284-y) contains supplementary material, which is available to authorized users.
Collapse
|
14
|
Ashraf M, Choudhary N, Hussain SS, Kamboh UA, Ashraf N. Role of intraoperative computed tomography scanner in modern neurosurgery - An early experience. Surg Neurol Int 2020; 11:247. [PMID: 32905376 PMCID: PMC7468186 DOI: 10.25259/sni_303_2020] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2020] [Accepted: 07/16/2020] [Indexed: 11/20/2022] Open
Abstract
Background: Intraoperative imaging addresses the limitations of frameless neuronavigation systems by providing real-time image updates. With the advent of new multidetector intraoperative computed tomography (CT), soft tissue can be visualized far better than before. We report the early departmental experience of our intraoperative CT scanner’s use in a wide range of technically challenging neurosurgical cases. Methods: We retrospectively analyzed the data of all patients in whom intraoperative CT scanner was utilized. Out of 31 patients, 24 (77.4%) were cranial and 8 (22.6%) spinal cases. There were 13 male (41.9%) and 18 (58.1%) female patients, age ranged from 1 to 83 years with a mean age of 34.29 years ±17.54 years. Seven patients underwent spinal surgery, 2 cases were of orbital tumors, and 16 intra-axial brain tumors, including 5 low- grade gliomas, 10 high-grade gliomas, and 1 colloid cyst. There were four sellar lesions and two multiloculated hydrocephalus. Results: The intraoperative CT scan guided us to correct screw placement and was crucial in managing four complex spinal instabilities. In intracranial lesions, 59% of cases were benefitted due to intraoperative CT scan. It helped in the precise placement of ventricular catheter in multiloculated hydrocephalus and external ventricular drain for a third ventricular colloid cyst. Conclusion: Intraoperative CT scan is safe and logistically and financially advantageous. It provides versatile benefits allowing for safe and maximal surgery, requiring minimum changes to an existing neurosurgical setup. Intraoperative CT scan provides clinical benefit in technically difficult cases and has a smooth workflow.
Collapse
Affiliation(s)
- Mohammad Ashraf
- rd Year Medical Student, University of Glasgow, Wolfson School of Medicine, Glasgow, Scotland, United Kingdom.,Visiting Medical Student, Allama Iqbal Medical College, Department of Neurosurgery, Jinnah Hospital, Lahore, Pakistan
| | - Nabeel Choudhary
- Department of Neurosurgery, Allama Iqbal Medical College, Jinnah Hospital, Lahore, Pakistan
| | - Syed Shahzad Hussain
- Department of Neurosurgery, Allama Iqbal Medical College, Jinnah Hospital, Lahore, Pakistan
| | - Usman Ahmad Kamboh
- Department of Neurosurgery, Allama Iqbal Medical College, Jinnah Hospital, Lahore, Pakistan
| | - Naveed Ashraf
- Department of Neurosurgery, Allama Iqbal Medical College, Jinnah Hospital, Lahore, Pakistan
| |
Collapse
|
15
|
Della Pepa GM, Ius T, Menna G, La Rocca G, Battistella C, Rapisarda A, Mazzucchi E, Pignotti F, Alexandre A, Marchese E, Olivi A, Sabatino G. "Dark corridors" in 5-ALA resection of high-grade gliomas: combining fluorescence-guided surgery and contrast-enhanced ultrasonography to better explore the surgical field. J Neurosurg Sci 2020; 63:688-696. [PMID: 31961118 DOI: 10.23736/s0390-5616.19.04862-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Increasing the extent of resection (EOR) is considered a main goal in high grade glioma (HGG) surgery. Significant advancements have been recently made to assist surgery: namely the use of 5-aminolevulinic acid (5ALA) and the application of contrast-enhanced ultrasound (CEUS) embody two of the most recently introduced tools in the neuro-oncology field. A combined approach including the two techniques has been suggested in literature. Our primary aim is to identify in which conditions CEUS final survey has a real impact in a 5-ALA guided context and assess which preoperative tumor characteristics, with specific attention to working corridors can predict strains of the fluorescence guided procedure and hence recommend the use of the combined technique. METHODS Forty-nine HGG glioma surgeries were performed at our institution with the abovementioned protocol between January 2016 and June 2016. Based on preoperative MRI, we stratified glioma characteristics according to three determinants: localization (deep versus superficial), size (<3.5 versus >3.5 cm) and shape (regular versus irregular). RESULTS CEUS modified 5-ALA guided resection in 11 cases (22.45%): this appeared to be associated with statistically significance to deep tumor localization (P=0.04) and irregular/multi-lobulated margins (P=0.003). On the other hand, tumor size alone did not appear as a statistically significant determinant. CONCLUSIONS When dark corridors are presents or when overlying brain parenchyma hinders illumination, drawbacks to the 5-ALA assistance can be expected, hence CEUS final survey has a crucial role of 'refinement'. In those selected cases, an integrated 5ALA+CEUS protocol was shown as advisable in EOR improvement.
Collapse
Affiliation(s)
- Giuseppe M Della Pepa
- Institute of Neurosurgery, A. Gemelli University Polyclinic, IRCCS and Foundation, Sacred Heart Catholic University, Rome, Italy -
| | - Tamara Ius
- Neurosurgery Unit, Department of Neuroscience, Santa Maria della Misericordia University Hospital, Udine, Italy
| | - Grazia Menna
- Institute of Neurosurgery, A. Gemelli University Polyclinic, IRCCS and Foundation, Sacred Heart Catholic University, Rome, Italy
| | - Giuseppe La Rocca
- Institute of Neurosurgery, A. Gemelli University Polyclinic, IRCCS and Foundation, Sacred Heart Catholic University, Rome, Italy.,Department of Neurosurgery, Mater Olbia Hospital, Olbia, Italy
| | | | - Alessandro Rapisarda
- Institute of Neurosurgery, A. Gemelli University Polyclinic, IRCCS and Foundation, Sacred Heart Catholic University, Rome, Italy
| | - Edoardo Mazzucchi
- Institute of Neurosurgery, A. Gemelli University Polyclinic, IRCCS and Foundation, Sacred Heart Catholic University, Rome, Italy
| | | | - Andrea Alexandre
- Institute of Neuroradiology, A. Gemelli University Polyclinic, IRCCS and Foundation, Sacred Heart Catholic University, Rome, Italy
| | - Enrico Marchese
- Institute of Neurosurgery, A. Gemelli University Polyclinic, IRCCS and Foundation, Sacred Heart Catholic University, Rome, Italy
| | - Alessandro Olivi
- Institute of Neurosurgery, A. Gemelli University Polyclinic, IRCCS and Foundation, Sacred Heart Catholic University, Rome, Italy
| | - Giovanni Sabatino
- Institute of Neurosurgery, A. Gemelli University Polyclinic, IRCCS and Foundation, Sacred Heart Catholic University, Rome, Italy.,Department of Neurosurgery, Mater Olbia Hospital, Olbia, Italy
| |
Collapse
|
16
|
Della Pepa GM, Ius T, La Rocca G, Gaudino S, Isola M, Pignotti F, Rapisarda A, Mazzucchi E, Giordano C, Dragonetti V, Chiesa S, Balducci M, Gessi M, Skrap M, Olivi A, Marchese E, Sabatino G. 5-Aminolevulinic Acid and Contrast-Enhanced Ultrasound: The Combination of the Two Techniques to Optimize the Extent of Resection in Glioblastoma Surgery. Neurosurgery 2020; 86:E529-E540. [PMID: 32186345 DOI: 10.1093/neuros/nyaa037] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2019] [Accepted: 12/15/2019] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND The survival benefit in maximizing resection in glioblastomas (GBMs) has been demonstrated by numerous studies. The true limit of infiltration of GBMs has been an overwhelming obstacle, and several technological advances have been introduced to improve the identification of residual tumors. OBJECTIVE To evaluate whether the integration of 5-aminolevulinic acid (5-ALA) with microbubble contrast-enhanced ultrasound (CEUS) improves residual tumor identification and has an impact on the extent of resection (EOR), overall survival (OS), and progression-free survival (PFS). METHODS A total of 230 GBM procedures were retrospectively studied. Cases were stratified according to the surgical procedure into 4 groups: 5-ALA- and CEUS-guided surgeries, 5-ALA-guided surgeries, CEUS-guided surgeries, and conventional microsurgical procedures. RESULTS Patients undergoing conventional microsurgical procedures showed the worst EORs compared to the assisted techniques (5-ALA and CEUS procedures). Both 5-ALA and CEUS techniques improved the EOR compared to conventional microsurgical procedures. However, their combination gave the best results in terms of the EOR (P = .0003). The median EOR% and the number of supramarginal resections are hence superior in the 5-ALA + CEUS + group compared to the others; this observation had consequences on PFS and OS in our series. CONCLUSION In terms of the EOR, the best results can be achieved through a combination of both techniques, where the 5-ALA-guided procedure is followed by a final survey with CEUS. Compared with other intraoperative imaging techniques, CEUS is a real-time, readily repeatable, safe, and inexpensive technique that provides valuable information to the surgeon before, during, and after resection.
Collapse
Affiliation(s)
- Giuseppe Maria Della Pepa
- Institute of Neurosurgery, Fondazione Policlinico Universitario Agostino Gemelli, IRCSS, Catholic University of Rome, Rome, Italy
| | - Tamara Ius
- Department of Neurosurgery, University Hospital, Udine, Italy
| | - Giuseppe La Rocca
- Institute of Neurosurgery, Fondazione Policlinico Universitario Agostino Gemelli, IRCSS, Catholic University of Rome, Rome, Italy
- Department of Neurosurgery, Mater Olbia Hospital, Olbia, Italy
| | - Simona Gaudino
- Institute of Radiology, Fondazione Policlinico Universitario Agostino Gemelli IRCSS, Catholic University of Rome, Rome, Italy
| | - Miriam Isola
- Department of Medicine, University of Udine, Udine, Italy
| | - Fabrizio Pignotti
- Institute of Neurosurgery, Fondazione Policlinico Universitario Agostino Gemelli, IRCSS, Catholic University of Rome, Rome, Italy
- Department of Neurosurgery, Mater Olbia Hospital, Olbia, Italy
| | - Alessandro Rapisarda
- Institute of Neurosurgery, Fondazione Policlinico Universitario Agostino Gemelli, IRCSS, Catholic University of Rome, Rome, Italy
| | - Edoardo Mazzucchi
- Institute of Neurosurgery, Fondazione Policlinico Universitario Agostino Gemelli, IRCSS, Catholic University of Rome, Rome, Italy
| | - Carolina Giordano
- Institute of Radiology, Fondazione Policlinico Universitario Agostino Gemelli IRCSS, Catholic University of Rome, Rome, Italy
| | - Valentino Dragonetti
- Institute of Radiology, Fondazione Policlinico Universitario Agostino Gemelli IRCSS, Catholic University of Rome, Rome, Italy
| | - Silvia Chiesa
- Department of Radiation Oncology, Fondazione Policlinico Universitario Agostino Gemelli IRCSSl, Catholic University of Rome, Rome, Italy
| | - Mario Balducci
- Department of Radiation Oncology, Fondazione Policlinico Universitario Agostino Gemelli IRCSSl, Catholic University of Rome, Rome, Italy
| | - Marco Gessi
- Department of Neuro-Pathology, Fondazione Policlinico Universitario Agostino Gemelli IRCSS, Catholic University of Rome, Rome, Italy
| | - Miran Skrap
- Department of Neurosurgery, University Hospital, Udine, Italy
| | - Alessandro Olivi
- Institute of Neurosurgery, Fondazione Policlinico Universitario Agostino Gemelli, IRCSS, Catholic University of Rome, Rome, Italy
| | - Enrico Marchese
- Institute of Neurosurgery, Fondazione Policlinico Universitario Agostino Gemelli, IRCSS, Catholic University of Rome, Rome, Italy
| | - Giovanni Sabatino
- Institute of Neurosurgery, Fondazione Policlinico Universitario Agostino Gemelli, IRCSS, Catholic University of Rome, Rome, Italy
- Department of Neurosurgery, Mater Olbia Hospital, Olbia, Italy
| |
Collapse
|
17
|
“Enhancing Vision” in High Grade Glioma Surgery: A Feasible Integrated 5-ALA + CEUS Protocol to Improve Radicality. World Neurosurg 2019; 129:401-403. [DOI: 10.1016/j.wneu.2019.06.127] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
|
18
|
Certo F, Stummer W, Farah JO, Freyschlag C, Visocchi M, Morrone A, Altieri R, Toccaceli G, Peschillo S, Thomè C, Jenkinson M, Barbagallo G. Supramarginal resection of glioblastoma: 5-ALA fluorescence, combined intraoperative strategies and correlation with survival. J Neurosurg Sci 2019; 63:625-632. [PMID: 31355623 DOI: 10.23736/s0390-5616.19.04787-8] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
INTRODUCTION Glioblastoma treatment requires a multidisciplinary approach involving oncologists, radiotherapists and surgeons. Surgery constitutes the initial step of the therapeutic strategy and its efficacy is dependent on the extent of resection (EOR). Over the last decade, the goal of surgical treatment was the resection of the contrast enhancement on T1 MRI, defined as gross-total resection (GTR). More recently, an increasing number of studies reports a positive impact on survival parameters of a more aggressive surgical strategy aiming to resect all peri-tumoral infiltrated areas. These areas are histologically characterized by the presence of pathological cells infiltrating normal white matter and surround the neoplastic core of glioblastoma identified by gadolinium enhancement in T1-weighted MR. Intuitively, the major risk of the so called supramarginal resection is related to the possibility of resecting functionally eloquent brain tissue. Several strategies have been proposed to maximize the safety of resection and minimize the occurrence of postoperative functional deficits. The aim of this review was to focus on the clinical impact of supramarginal resection of glioblastomas, highlighting the role of image-guided surgery combined with neuromonitoring to increase surgical safety and efficacy. EVIDENCE ACQUISITION The MEDLINE database has been queried for the literature research. EVIDENCE SYNTHESIS Ten studies matched the inclusion criteria, reporting a global number of 3221 patients. CONCLUSIONS The current evidence suggests a positive correlation between a more extensive resection based on FLAIR abnormal areas and overall survival.
Collapse
Affiliation(s)
- Francesco Certo
- Department of Neurological Surgery, G. Rodolico Polyclinic University Hospital, Catania, Italy - .,Interdisciplinary Research Center on Brain Tumors Diagnosis and Treatment, University of Catania, Catania, Italy -
| | - Walter Stummer
- Department of Neurosurgery, University Hospital of Münster, Münster, Germany
| | - Jibril O Farah
- The Walton Centre for Neurology and Neurosurgery, Liverpool, UK
| | - Christian Freyschlag
- Department of Neurosurgery, Medizinische Universität Innsbruck, Innsbruck, Austria
| | | | - Antonio Morrone
- Department of Neurological Surgery, G. Rodolico Polyclinic University Hospital, Catania, Italy
| | - Roberto Altieri
- Department of Neurological Surgery, G. Rodolico Polyclinic University Hospital, Catania, Italy
| | - Giada Toccaceli
- Department of Neurological Surgery, G. Rodolico Polyclinic University Hospital, Catania, Italy
| | - Simone Peschillo
- Department of Neurological Surgery, G. Rodolico Polyclinic University Hospital, Catania, Italy.,Interdisciplinary Research Center on Brain Tumors Diagnosis and Treatment, University of Catania, Catania, Italy
| | - Claudius Thomè
- Department of Neurosurgery, Medizinische Universität Innsbruck, Innsbruck, Austria
| | | | - Giuseppe Barbagallo
- Department of Neurological Surgery, G. Rodolico Polyclinic University Hospital, Catania, Italy.,Interdisciplinary Research Center on Brain Tumors Diagnosis and Treatment, University of Catania, Catania, Italy
| |
Collapse
|
19
|
Intraoperative Computed Tomography and Awake Craniotomy: A Useful and Safe Combination in Brain Surgery. World Neurosurg 2018; 119:e159-e166. [PMID: 30031198 DOI: 10.1016/j.wneu.2018.07.078] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2018] [Revised: 07/08/2018] [Accepted: 07/09/2018] [Indexed: 11/20/2022]
Abstract
BACKGROUND Awake surgery is an effective technique to improve safety in surgical resection of lesions involving eloquent areas of the brain. Intraoperative imaging guidance and neuronavigation are widely applied in neurosurgical procedures. However, data on the application of intraoperative imaging to awake craniotomies are limited. We report our experience with intraoperative computed tomography (i-CT) during awake surgery, focusing on technical feasibility and effectiveness. METHODS AND RESULTS Four patients with a lesion located in an eloquent area of the brain-1 with a cavernous hemangioma, 1 with a high-grade glioma, and 2 with a low-grade glioma (LGG)-underwent awake surgery with neuronavigation guidance. In all patients, i-CT was used to evaluate the completeness of resection or the extent of residual tumor. Intraoperative ultrasound was also used during microsurgery to verify the presence of residual tumor. The use of i-CT us allowed to obtain updated images for neuronavigation and to correct for brain shift. CONCLUSIONS i-CT in awake surgery is reliable and effective. It does not significantly affect the duration of surgery and does not add stress for the patient. The possibility to correct for brain shift also in awake patients can increase the precision and accuracy of surgery, particularly in cases of LGG, avoiding the resection of normal white matter or tumor remnants in noneloquent areas.
Collapse
|
20
|
Awake Craniotomy for Tumor Resection: Further Optimizing Therapy of Brain Tumors. ACTA NEUROCHIRURGICA. SUPPLEMENT 2017; 124:309-313. [PMID: 28120089 DOI: 10.1007/978-3-319-39546-3_45] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/15/2023]
Abstract
In recent years more and more data have emerged linking the most radical resection to prolonged survival in patients harboring brain tumors. Since total tumor resection could increase postoperative morbidity, many methods have been suggested to reduce the risk of postoperative neurological deficits: awake craniotomy with the possibility of continuous patient-surgeon communication is one of the possibilities of finding out how radical a tumor resection can possibly be without causing permanent harm to the patient.In 1994 we started to perform awake craniotomy for glioma resection. In 2005 the use of intraoperative high-field magnetic resonance imaging (MRI) was included in the standard tumor therapy protocol. Here we review our experience in performing awake surgery for gliomas, gained in 219 patients.Patient selection by the operating surgeon and a neuropsychologist is of primary importance: the patient should feel as if they are part of the surgical team fighting against the tumor. The patient will undergo extensive neuropsychological testing, functional MRI, and fiber tractography in order to define the relationship between the tumor and the functionally relevant brain areas. Attention needs to be given at which particular time during surgery the intraoperative MRI is performed. Results from part of our series (without and with ioMRI scan) are presented.
Collapse
|
21
|
Prada F, Vitale V, Del Bene M, Boffano C, Sconfienza LM, Pinzi V, Mauri G, Solbiati L, Sakas G, Kolev V, D'Incerti L, DiMeco F. Contrast-enhanced MR Imaging versus Contrast-enhanced US: A Comparison in Glioblastoma Surgery by Using Intraoperative Fusion Imaging. Radiology 2017; 285:242-249. [PMID: 28562204 DOI: 10.1148/radiol.2017161206] [Citation(s) in RCA: 43] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/18/2023]
Abstract
Purpose To compare contrast material enhancement of glioblastoma multiforme (GBM) with intraoperative contrast-enhanced ultrasonography (US) versus that with preoperative gadolinium-enhanced T1-weighted magnetic resonance (MR) imaging by using real-time fusion imaging. Materials and Methods Ten patients with GBM were retrospectively identified by using routinely collected, anonymized data. Navigated contrast-enhanced US was performed after intravenous administration of contrast material before tumor resection. All patients underwent tumor excision with navigated intraoperative US guidance with use of fusion imaging between real-time intraoperative US and preoperative MR imaging. With use of fusion imaging, glioblastoma contrast enhancement at contrast-enhanced US (regarding location, morphologic features, margins, dimensions, and pattern) was compared with that at gadolinium-enhanced T1-weighted MR imaging. Results Fusion imaging for virtual navigation enabled matching of real-time contrast-enhanced US scans to corresponding coplanar preoperative gadolinium-enhanced T1-weighted MR images in all cases, with a positional discrepancy of less than 2 mm. Contrast enhancement of gadolinium-enhanced T1-weighted MR imaging and contrast-enhanced US was superimposable in all cases with regard to location, margins, dimensions, and morphologic features. The qualitative analysis of contrast enhancement pattern demonstrated a similar distribution in contrast-enhanced US and gadolinium-enhanced T1-weighted MR imaging in nine patients: Seven lesions showed peripheral inhomogeneous ring enhancement, and two lesions showed a prevalent nodular pattern. In one patient, the contrast enhancement pattern differed between the two modalities: Contrast-enhanced US showed enhancement of the entire bulk of the tumor, whereas gadolinium-enhanced T1-weighted MR imaging demonstrated peripheral contrast enhancement. Conclusion Glioblastoma contrast enhancement with contrast-enhanced US is superimposable on that provided with preoperative gadolinium-enhanced T1-weighted MR imaging regarding location, margins, morphologic features, and dimensions, with a similar enhancement pattern in most cases. Thus, contrast-enhanced US is of potential use in the surgical management of GBM. © RSNA, 2017 Online supplemental material is available for this article.
Collapse
Affiliation(s)
- Francesco Prada
- From the Department of Neurosurgery (F.P., M.D.B., F.D.), Department of Neuroradiology (C.B., L.D.), and Radiotherapy Unit (V.P.), Fondazione IRCCS Istituto Neurologico "C. Besta," Via Celoria n.11, 20133 Milan, Italy; Department of Imaging and Radiation Therapy, Azienda Socio-sanitaria Territoriale di Lecco, Lecco, Italy (V.V.); Unit of Diagnostic and Interventional Radiology, IRCCS Istituto Ortopedico Galeazzi, Milan, Italy (L.M.S.); Department of Biomedical Sciences for Health, University of Milan, Milan, Italy (L.M.S.); Department of Interventional Radiology, Istituto Europeo di Oncologia, Milan, Italy (G.M.); Department of Radiology, Humanitas Research Hospital, Rozzano, Italy (L.S.); Department of Research and Development, MedCom, Darmstadt, Germany (G.S., V.K.); and Department of Neurologic Surgery, Johns Hopkins Medical School, Baltimore, Md (F.D.)
| | - Valerio Vitale
- From the Department of Neurosurgery (F.P., M.D.B., F.D.), Department of Neuroradiology (C.B., L.D.), and Radiotherapy Unit (V.P.), Fondazione IRCCS Istituto Neurologico "C. Besta," Via Celoria n.11, 20133 Milan, Italy; Department of Imaging and Radiation Therapy, Azienda Socio-sanitaria Territoriale di Lecco, Lecco, Italy (V.V.); Unit of Diagnostic and Interventional Radiology, IRCCS Istituto Ortopedico Galeazzi, Milan, Italy (L.M.S.); Department of Biomedical Sciences for Health, University of Milan, Milan, Italy (L.M.S.); Department of Interventional Radiology, Istituto Europeo di Oncologia, Milan, Italy (G.M.); Department of Radiology, Humanitas Research Hospital, Rozzano, Italy (L.S.); Department of Research and Development, MedCom, Darmstadt, Germany (G.S., V.K.); and Department of Neurologic Surgery, Johns Hopkins Medical School, Baltimore, Md (F.D.)
| | - Massimiliano Del Bene
- From the Department of Neurosurgery (F.P., M.D.B., F.D.), Department of Neuroradiology (C.B., L.D.), and Radiotherapy Unit (V.P.), Fondazione IRCCS Istituto Neurologico "C. Besta," Via Celoria n.11, 20133 Milan, Italy; Department of Imaging and Radiation Therapy, Azienda Socio-sanitaria Territoriale di Lecco, Lecco, Italy (V.V.); Unit of Diagnostic and Interventional Radiology, IRCCS Istituto Ortopedico Galeazzi, Milan, Italy (L.M.S.); Department of Biomedical Sciences for Health, University of Milan, Milan, Italy (L.M.S.); Department of Interventional Radiology, Istituto Europeo di Oncologia, Milan, Italy (G.M.); Department of Radiology, Humanitas Research Hospital, Rozzano, Italy (L.S.); Department of Research and Development, MedCom, Darmstadt, Germany (G.S., V.K.); and Department of Neurologic Surgery, Johns Hopkins Medical School, Baltimore, Md (F.D.)
| | - Carlo Boffano
- From the Department of Neurosurgery (F.P., M.D.B., F.D.), Department of Neuroradiology (C.B., L.D.), and Radiotherapy Unit (V.P.), Fondazione IRCCS Istituto Neurologico "C. Besta," Via Celoria n.11, 20133 Milan, Italy; Department of Imaging and Radiation Therapy, Azienda Socio-sanitaria Territoriale di Lecco, Lecco, Italy (V.V.); Unit of Diagnostic and Interventional Radiology, IRCCS Istituto Ortopedico Galeazzi, Milan, Italy (L.M.S.); Department of Biomedical Sciences for Health, University of Milan, Milan, Italy (L.M.S.); Department of Interventional Radiology, Istituto Europeo di Oncologia, Milan, Italy (G.M.); Department of Radiology, Humanitas Research Hospital, Rozzano, Italy (L.S.); Department of Research and Development, MedCom, Darmstadt, Germany (G.S., V.K.); and Department of Neurologic Surgery, Johns Hopkins Medical School, Baltimore, Md (F.D.)
| | - Luca Maria Sconfienza
- From the Department of Neurosurgery (F.P., M.D.B., F.D.), Department of Neuroradiology (C.B., L.D.), and Radiotherapy Unit (V.P.), Fondazione IRCCS Istituto Neurologico "C. Besta," Via Celoria n.11, 20133 Milan, Italy; Department of Imaging and Radiation Therapy, Azienda Socio-sanitaria Territoriale di Lecco, Lecco, Italy (V.V.); Unit of Diagnostic and Interventional Radiology, IRCCS Istituto Ortopedico Galeazzi, Milan, Italy (L.M.S.); Department of Biomedical Sciences for Health, University of Milan, Milan, Italy (L.M.S.); Department of Interventional Radiology, Istituto Europeo di Oncologia, Milan, Italy (G.M.); Department of Radiology, Humanitas Research Hospital, Rozzano, Italy (L.S.); Department of Research and Development, MedCom, Darmstadt, Germany (G.S., V.K.); and Department of Neurologic Surgery, Johns Hopkins Medical School, Baltimore, Md (F.D.)
| | - Valentina Pinzi
- From the Department of Neurosurgery (F.P., M.D.B., F.D.), Department of Neuroradiology (C.B., L.D.), and Radiotherapy Unit (V.P.), Fondazione IRCCS Istituto Neurologico "C. Besta," Via Celoria n.11, 20133 Milan, Italy; Department of Imaging and Radiation Therapy, Azienda Socio-sanitaria Territoriale di Lecco, Lecco, Italy (V.V.); Unit of Diagnostic and Interventional Radiology, IRCCS Istituto Ortopedico Galeazzi, Milan, Italy (L.M.S.); Department of Biomedical Sciences for Health, University of Milan, Milan, Italy (L.M.S.); Department of Interventional Radiology, Istituto Europeo di Oncologia, Milan, Italy (G.M.); Department of Radiology, Humanitas Research Hospital, Rozzano, Italy (L.S.); Department of Research and Development, MedCom, Darmstadt, Germany (G.S., V.K.); and Department of Neurologic Surgery, Johns Hopkins Medical School, Baltimore, Md (F.D.)
| | - Giovanni Mauri
- From the Department of Neurosurgery (F.P., M.D.B., F.D.), Department of Neuroradiology (C.B., L.D.), and Radiotherapy Unit (V.P.), Fondazione IRCCS Istituto Neurologico "C. Besta," Via Celoria n.11, 20133 Milan, Italy; Department of Imaging and Radiation Therapy, Azienda Socio-sanitaria Territoriale di Lecco, Lecco, Italy (V.V.); Unit of Diagnostic and Interventional Radiology, IRCCS Istituto Ortopedico Galeazzi, Milan, Italy (L.M.S.); Department of Biomedical Sciences for Health, University of Milan, Milan, Italy (L.M.S.); Department of Interventional Radiology, Istituto Europeo di Oncologia, Milan, Italy (G.M.); Department of Radiology, Humanitas Research Hospital, Rozzano, Italy (L.S.); Department of Research and Development, MedCom, Darmstadt, Germany (G.S., V.K.); and Department of Neurologic Surgery, Johns Hopkins Medical School, Baltimore, Md (F.D.)
| | - Luigi Solbiati
- From the Department of Neurosurgery (F.P., M.D.B., F.D.), Department of Neuroradiology (C.B., L.D.), and Radiotherapy Unit (V.P.), Fondazione IRCCS Istituto Neurologico "C. Besta," Via Celoria n.11, 20133 Milan, Italy; Department of Imaging and Radiation Therapy, Azienda Socio-sanitaria Territoriale di Lecco, Lecco, Italy (V.V.); Unit of Diagnostic and Interventional Radiology, IRCCS Istituto Ortopedico Galeazzi, Milan, Italy (L.M.S.); Department of Biomedical Sciences for Health, University of Milan, Milan, Italy (L.M.S.); Department of Interventional Radiology, Istituto Europeo di Oncologia, Milan, Italy (G.M.); Department of Radiology, Humanitas Research Hospital, Rozzano, Italy (L.S.); Department of Research and Development, MedCom, Darmstadt, Germany (G.S., V.K.); and Department of Neurologic Surgery, Johns Hopkins Medical School, Baltimore, Md (F.D.)
| | - Georgios Sakas
- From the Department of Neurosurgery (F.P., M.D.B., F.D.), Department of Neuroradiology (C.B., L.D.), and Radiotherapy Unit (V.P.), Fondazione IRCCS Istituto Neurologico "C. Besta," Via Celoria n.11, 20133 Milan, Italy; Department of Imaging and Radiation Therapy, Azienda Socio-sanitaria Territoriale di Lecco, Lecco, Italy (V.V.); Unit of Diagnostic and Interventional Radiology, IRCCS Istituto Ortopedico Galeazzi, Milan, Italy (L.M.S.); Department of Biomedical Sciences for Health, University of Milan, Milan, Italy (L.M.S.); Department of Interventional Radiology, Istituto Europeo di Oncologia, Milan, Italy (G.M.); Department of Radiology, Humanitas Research Hospital, Rozzano, Italy (L.S.); Department of Research and Development, MedCom, Darmstadt, Germany (G.S., V.K.); and Department of Neurologic Surgery, Johns Hopkins Medical School, Baltimore, Md (F.D.)
| | - Velizar Kolev
- From the Department of Neurosurgery (F.P., M.D.B., F.D.), Department of Neuroradiology (C.B., L.D.), and Radiotherapy Unit (V.P.), Fondazione IRCCS Istituto Neurologico "C. Besta," Via Celoria n.11, 20133 Milan, Italy; Department of Imaging and Radiation Therapy, Azienda Socio-sanitaria Territoriale di Lecco, Lecco, Italy (V.V.); Unit of Diagnostic and Interventional Radiology, IRCCS Istituto Ortopedico Galeazzi, Milan, Italy (L.M.S.); Department of Biomedical Sciences for Health, University of Milan, Milan, Italy (L.M.S.); Department of Interventional Radiology, Istituto Europeo di Oncologia, Milan, Italy (G.M.); Department of Radiology, Humanitas Research Hospital, Rozzano, Italy (L.S.); Department of Research and Development, MedCom, Darmstadt, Germany (G.S., V.K.); and Department of Neurologic Surgery, Johns Hopkins Medical School, Baltimore, Md (F.D.)
| | - Ludovico D'Incerti
- From the Department of Neurosurgery (F.P., M.D.B., F.D.), Department of Neuroradiology (C.B., L.D.), and Radiotherapy Unit (V.P.), Fondazione IRCCS Istituto Neurologico "C. Besta," Via Celoria n.11, 20133 Milan, Italy; Department of Imaging and Radiation Therapy, Azienda Socio-sanitaria Territoriale di Lecco, Lecco, Italy (V.V.); Unit of Diagnostic and Interventional Radiology, IRCCS Istituto Ortopedico Galeazzi, Milan, Italy (L.M.S.); Department of Biomedical Sciences for Health, University of Milan, Milan, Italy (L.M.S.); Department of Interventional Radiology, Istituto Europeo di Oncologia, Milan, Italy (G.M.); Department of Radiology, Humanitas Research Hospital, Rozzano, Italy (L.S.); Department of Research and Development, MedCom, Darmstadt, Germany (G.S., V.K.); and Department of Neurologic Surgery, Johns Hopkins Medical School, Baltimore, Md (F.D.)
| | - Francesco DiMeco
- From the Department of Neurosurgery (F.P., M.D.B., F.D.), Department of Neuroradiology (C.B., L.D.), and Radiotherapy Unit (V.P.), Fondazione IRCCS Istituto Neurologico "C. Besta," Via Celoria n.11, 20133 Milan, Italy; Department of Imaging and Radiation Therapy, Azienda Socio-sanitaria Territoriale di Lecco, Lecco, Italy (V.V.); Unit of Diagnostic and Interventional Radiology, IRCCS Istituto Ortopedico Galeazzi, Milan, Italy (L.M.S.); Department of Biomedical Sciences for Health, University of Milan, Milan, Italy (L.M.S.); Department of Interventional Radiology, Istituto Europeo di Oncologia, Milan, Italy (G.M.); Department of Radiology, Humanitas Research Hospital, Rozzano, Italy (L.S.); Department of Research and Development, MedCom, Darmstadt, Germany (G.S., V.K.); and Department of Neurologic Surgery, Johns Hopkins Medical School, Baltimore, Md (F.D.)
| |
Collapse
|
22
|
Francaviglia N, Iacopino DG, Costantino G, Villa A, Impallaria P, Meli F, Maugeri R. Fluorescein for resection of high-grade gliomas: A safety study control in a single center and review of the literature. Surg Neurol Int 2017; 8:145. [PMID: 28781922 PMCID: PMC5523479 DOI: 10.4103/sni.sni_89_17] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2017] [Accepted: 05/18/2017] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND The importance of a complete resection of high-grade gliomas (HGGs) has been highlighted in scientific literature, in order to limit tumor recurrence and above all to improve disease-free survival rates. Several fluorescent biomarkers have been tested to improve intraoperative identification of residual tumor; 5-aminolevulinic acid (5-ALA) and fluorescein sodium (FS) are now starting to play a central role in glioma surgery. We performed a retrospective analysis on 47 patients operated for HGGs. Here we report our preliminary data. METHODS Data of 47 consecutive patients with HGG have been collected in our study (25 males, 22 females; mean age: 60.3 years, range: 27-86 years). Fluorescein (5 mg/kg of body weight) was injected intravenously right after the induction of general anesthesia. A YELLOW 560 filter was used on an OPMI Pentero 900 microscope (Carl Zeiss Meditec, Oberkochen, Germany) to complete a microsurgical tumor removal. Glioma resection and quality of life were evaluated preoperative and postoperatively. RESULTS Gross total resection (GTR) was achieved in 53.2% (n = 25) of patients. A subtotal resection (STR) (>95%) was achieved in 29.8% (n = 14), while a partial resection (PR) (<95%) was obtained in 17% (n = 8) of patients. Overall, in 83% (n = 39) of patients who underwent fluorescence-guided surgery the resection rate achieved was >95%. No adverse effects correlated to fluorescein have been recorded. CONCLUSION Fluorescein seems to be safe and effective in the resection of HGGs, allowing a high rate of gross total removal of contrast enhanced areas.
Collapse
Affiliation(s)
| | - Domenico Gerardo Iacopino
- Department of Experimental Biomedicine and Clinical Neurosciences, School of Medicine, Neurosurgical Clinic, AOUP “Paolo Giaccone”, Palermo, Italy
| | | | | | | | - Francesco Meli
- Division of Neurosurgery, ARNAS Civico Hospital, Palermo, Italy
| | - Rosario Maugeri
- Department of Experimental Biomedicine and Clinical Neurosciences, School of Medicine, Neurosurgical Clinic, AOUP “Paolo Giaccone”, Palermo, Italy
| |
Collapse
|
23
|
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.
Collapse
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.
| |
Collapse
|