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da Silva EB, Ramina R, Novak Filho JL, Jung GS, Bornancin GX, Neto MC. Pharmaceutical equivalent 5-aminolevulinic acid fluorescence guided resection of central nervous system tumors: feasibility, safeness and cost-benefit considerations. J Neurooncol 2024; 168:555-562. [PMID: 38709355 DOI: 10.1007/s11060-024-04698-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2024] [Accepted: 04/25/2024] [Indexed: 05/07/2024]
Abstract
PURPOSE 5-aminolevulinic acid (5-ALA) fluorescence-guided resection (FGR) has been an essential tool in the 'standard of care' of malignant gliomas. Over the last two decades, its indications have been extended to other neoplasms, such as metastases and meningiomas. However, its availability and cost-benefit still pose a challenge for widespread use. The present article reports a retrospective series of 707 cases of central nervous system (CNS) tumors submitted to FGR with pharmacological equivalent 5-ALA and discusses financial implications, feasibility and safeness. METHODS From December 2015 to February 2024, a retrospective single institution series of 707 cases of 5-ALA FGR were analyzed. Age, gender, 5-ALA dosage, intraoperative fluorescence finding, diagnosis and adverse effects were recorded. Financial impact in the surgical treatment cost were also reported. RESULTS there was an additional cost estimated in $300 dollars for each case, increasing from 2,37 to 3,28% of the total hospitalization cost. There were 19 (2,69%) cases of asymptomatic photosensitive reaction and 2 (0,28%) cases of photosensitive reaction requiring symptomatic treatment. 1 (0,14%) patient had a cutaneous rash sustained for up to 10 days. No other complications related to the method were evident. In 3 (0,42%) cases of patients with intracranial hypertension, there was vomiting after administration. CONCLUSION FGR with pharmacological equivalent 5-ALA can be considered safe and efficient and incorporates a small increase in hospital expenses. It constitutes a reliable solution in avoiding prohibitive costs worldwide, especially in countries where commercial 5-ALA is unavailable.
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Affiliation(s)
- Erasmo Barros da Silva
- Division of Neurooncology, Department of Neurosurgery, Instituto de Neurologia de Curitiba, Rua Jeremias Maciel Perretto, 300 - Campo Comprido, 81210-310, Curitiba, PR, Brazil.
| | - Ricardo Ramina
- Division of Neurooncology, Department of Neurosurgery, Instituto de Neurologia de Curitiba, Rua Jeremias Maciel Perretto, 300 - Campo Comprido, 81210-310, Curitiba, PR, Brazil
| | - Jorge Luis Novak Filho
- Division of Neurooncology, Department of Neurosurgery, Instituto de Neurologia de Curitiba, Rua Jeremias Maciel Perretto, 300 - Campo Comprido, 81210-310, Curitiba, PR, Brazil
| | - Gustavo Simiano Jung
- Division of Neurooncology, Department of Neurosurgery, Instituto de Neurologia de Curitiba, Rua Jeremias Maciel Perretto, 300 - Campo Comprido, 81210-310, Curitiba, PR, Brazil
| | - Giulia Xavier Bornancin
- Division of Neurooncology, Department of Neurosurgery, Instituto de Neurologia de Curitiba, Rua Jeremias Maciel Perretto, 300 - Campo Comprido, 81210-310, Curitiba, PR, Brazil
| | - Maurício Coelho Neto
- Division of Neurooncology, Department of Neurosurgery, Instituto de Neurologia de Curitiba, Rua Jeremias Maciel Perretto, 300 - Campo Comprido, 81210-310, Curitiba, PR, Brazil
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Anichini G, Leiloglou M, Hu Z, O'Neill K, Daniel Elson. Hyperspectral and multispectral imaging in neurosurgery: a systematic literature review and meta-analysis. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2024:108293. [PMID: 38658267 DOI: 10.1016/j.ejso.2024.108293] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2023] [Revised: 01/21/2024] [Accepted: 03/20/2024] [Indexed: 04/26/2024]
Abstract
INTRODUCTION The neuro-surgical community is witnessing a rising interest for surgical application of multispectral/hyperspectral imaging. Several potential technical applications of this optical imaging are reported, but the set-up is variable and so are the processing methods. We present a systematic review of the relevant literature on the topic. MATERIALS AND METHODS A literature search based on the PRISMA principles was performed on PubMed, SCOPUS, and Web of Science, using MESH terms and Boolean operators. Papers regarding intra-operative in-vivo application of multispectral and/or hyperspectral imaging in humans during neurosurgical procedures were included. Papers reporting technologies related to radiological applications were excluded. A meta-analysis on the performance metrics was also conducted. RESULTS Our search string retrieved 20 papers. The main applications of optical imaging during neurosurgery concern tumour detection and improvement of the extent of resection (15 papers) or visualization of perfusion changes during neuro-oncology or neuro-vascular surgery (5 papers). All the retrieved articles were pilot studies, proof of concepts, or case reports, with limited number of patients recruited. Sensitivity, specificity, and accuracy were promising in most of the reports, but the metanalysis showed heterogeneous approaches and results among studies. CONCLUSIONS The present review shows that several approaches are currently being tested to integrate hyperspectral imaging in neurosurgery, but most of the studies reported a limited pool of patients, with different approaches to data collection and analysis. Further studies on larger cohorts of patients are therefore desirable to fully explore the potential of this imaging technique.
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Affiliation(s)
- Giulio Anichini
- Department of Brain Sciences, Imperial College of London, United Kingdom; Department of Neurosurgery, Neuroscience, Imperial College Healthcare NHS Trust, United Kingdom.
| | - Maria Leiloglou
- Department of Surgery and Cancer, Imperial College of London, United Kingdom; The Hamlyn Centre, Imperial College of London, United Kingdom
| | - Zepeng Hu
- Department of Surgery and Cancer, Imperial College of London, United Kingdom; The Hamlyn Centre, Imperial College of London, United Kingdom
| | - Kevin O'Neill
- Department of Brain Sciences, Imperial College of London, United Kingdom; Department of Neurosurgery, Neuroscience, Imperial College Healthcare NHS Trust, United Kingdom
| | - Daniel Elson
- Department of Surgery and Cancer, Imperial College of London, United Kingdom; The Hamlyn Centre, Imperial College of London, United Kingdom
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3
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Park JS, Yoon T, Park SA, Lee BH, Jeun SS, Eom TJ. Delineation of three-dimensional tumor margins based on normalized absolute difference mapping via volumetric optical coherence tomography. Sci Rep 2024; 14:7984. [PMID: 38575630 PMCID: PMC10994936 DOI: 10.1038/s41598-024-56239-3] [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: 06/14/2023] [Accepted: 03/04/2024] [Indexed: 04/06/2024] Open
Abstract
The extent of surgical resection is an important prognostic factor in the treatment of patients with glioblastoma. Optical coherence tomography (OCT) imaging is one of the adjunctive methods available to achieve the maximal surgical resection. In this study, the tumor margins were visualized with the OCT image obtained from a murine glioma model. A commercialized human glioblastoma cell line (U-87) was employed to develop the orthotopic murine glioma model. A swept-source OCT (SS-OCT) system of 1300 nm was used for three-dimensional imaging. Based on the OCT intensity signal, which was obtained via accumulation of each A-scan data, an en-face optical attenuation coefficient (OAC) map was drawn. Due to the limited working distance of the focused beam, OAC values decrease with depth, and using the OAC difference in the superficial area was chosen to outline the tumor boundary, presenting a challenge in analyzing the tumor margin along the depth direction. To overcome this and enable three-dimensional tumor margin detection, we converted the en-face OAC map into an en-face difference map with x- and y-directions and computed the normalized absolute difference (NAD) at each depth to construct a volumetric NAD map, which was compared with the corresponding H&E-stained image. The proposed method successfully revealed the tumor margin along the peripheral boundaries as well as the margin depth. We believe this method can serve as a useful adjunct in glioma surgery, with further studies necessary for real-world practical applications.
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Affiliation(s)
- Jae-Sung Park
- Department of Neurosurgery, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, 222 Banpo-daero, Seocho-gu, Seoul, 06591, Republic of Korea
| | - Taeil Yoon
- School of Electrical Engineering and Computer Science, Gwangju Institute of Science and Technology (GIST), Gwangju, Republic of Korea
| | - Soon A Park
- Department of Biomedicine and Health Science, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Byeong Ha Lee
- School of Electrical Engineering and Computer Science, Gwangju Institute of Science and Technology (GIST), Gwangju, Republic of Korea
| | - Sin-Soo Jeun
- Department of Neurosurgery, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, 222 Banpo-daero, Seocho-gu, Seoul, 06591, Republic of Korea.
- Department of Biomedicine and Health Science, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea.
| | - Tae Joong Eom
- Department of Cogno-Mechatronics Engineering, Pusan National University, Busan, 46241, Republic of Korea.
- Engineering Research Center for Color-Modulated Extra-Sensory Perception Technology, Pusan National University, Busan, 46241, Republic of Korea.
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Grygoryev K, Lu H, Sørensen S, Talebi Varnosfaderani O, Georgel R, Li L, Burke R, Andersson-Engels S. Miniature, multi-dichroic instrument for measuring the concentration of multiple fluorophores. BIOMEDICAL OPTICS EXPRESS 2024; 15:2377-2391. [PMID: 38633072 PMCID: PMC11019676 DOI: 10.1364/boe.516574] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/27/2023] [Revised: 03/05/2024] [Accepted: 03/06/2024] [Indexed: 04/19/2024]
Abstract
Identification of tumour margins during resection of the brain is critical for improving the post-operative outcomes. Due to the highly infiltrative nature of glioblastoma multiforme (GBM) and limited intraoperative visualization of the tumour margin, incomplete surgical resection has been observed to occur in up to 80 % of GBM cases, leading to nearly universal tumour recurrence and overall poor prognosis of 14.6 months median survival. This research presents a miniaturized, SiPMT-based optical system for simultaneous measurement of powerful DRS and weak auto-fluorescence for brain tumour detection. The miniaturisation of the optical elements confined the spatial separation of eight select wavelengths into footprint measuring 1.5 × 2 × 16 mm. The small footprint enables this technology to be integrated with existing surgical guidance instruments in the operating room. It's dynamic ability to subtract any background illumination and measure signal intensities across a broad range from pW to mWs make this design much more suitable for clinical environments as compared to spectrometer-based systems with limited dynamic ranges and high integration times. Measurements using optical tissue phantoms containing mixed fluorophores demonstrate correlation coefficients between the fitted response and actual concentration using PLS regression being 0.95, 0.87 and 0.97 for NADH, FAD and PpIX , respectively. These promising results indicate that our proposed miniaturized instrument could serve as an effective alternative in operating rooms, assisting surgeons in identifying brain tumours to achieving positive surgical outcomes for patients.
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Affiliation(s)
| | - Huihui Lu
- Tyndall National Institute, Lee Maltings Complex, Dyke Parade, Cork, Ireland
| | - Simon Sørensen
- Tyndall National Institute, Lee Maltings Complex, Dyke Parade, Cork, Ireland
| | | | - Rachel Georgel
- Tyndall National Institute, Lee Maltings Complex, Dyke Parade, Cork, Ireland
| | - Liyao Li
- Tyndall National Institute, Lee Maltings Complex, Dyke Parade, Cork, Ireland
| | - Ray Burke
- Tyndall National Institute, Lee Maltings Complex, Dyke Parade, Cork, Ireland
| | - Stefan Andersson-Engels
- Tyndall National Institute, Lee Maltings Complex, Dyke Parade, Cork, Ireland
- Department of Physics, University College Cork, College Road, Cork, Ireland
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Fredericks K, Kriel J, Engelbrecht L, Mercea PA, Widhalm G, Harrington B, Vlok I, Loos B. 5-ALA localises to the autophagy compartment and increases its fluorescence upon autophagy enhancement through caloric restriction and spermidine treatment in human glioblastoma. Biochem Biophys Rep 2024; 37:101642. [PMID: 38288282 PMCID: PMC10823107 DOI: 10.1016/j.bbrep.2024.101642] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2023] [Revised: 12/29/2023] [Accepted: 01/08/2024] [Indexed: 01/31/2024] Open
Abstract
Glioblastoma Multiforme (GBM) is the most invasive and prevalent Central Nervous System (CNS) malignancy. It is characterised by diffuse infiltrative growth and metabolic dysregulation that impairs the extent of surgical resection (EoR), contributing to its poor prognosis. 5-Aminolevulinic acid (5-ALA) fluorescence-guided surgical resection (FGR) takes advantage of the preferential generation of 5-ALA-derived fluorescence signal in glioma cells, thereby improving visualisation and enhancing the EoR. However, despite 5-ALA FGR is a widely used technique in the surgical management of malignant gliomas, the infiltrative tumour margins usually show only vague or no visible fluorescence and thus a significant amount of residual tumour tissue may hence remain in the resection cavity, subsequently driving tumour recurrence. To investigate the molecular mechanisms that govern the preferential accumulation of 5-ALA in glioma cells, we investigated the precise subcellular localisation of 5-ALA signal using Correlative Light and Electron Microscopy (CLEM) and colocalisation analyses in U118MG glioma cells. Our results revealed strong 5-ALA signal localisation in the autophagy compartment - specifically autolysosomes and lysosomes. Flow cytometry was employed to investigate whether autophagy enhancement through spermidine treatment (SPD) or nutrient deprivation/caloric restriction (CR) would enhance 5-ALA fluorescence signal generation. Indeed, SPD, CR and a combination of SPD/CR treatment significantly increased 5-ALA signal intensity, with a most robust increase in signal intensity observed in the combination treatment of SPD/CR. When using 3-D glioma spheroids to assess the effect of 5-ALA on cellular ultrastructure, we demonstrate that 5-ALA exposure leads to cytoplasmic disruption, vacuolarisation and large-scale mitophagy induction. These findings not only suggest a critical role for the autophagy compartment in 5-ALA engagement and signal generation but also point towards a novel and practically feasible approach to enhance 5-ALA fluorescence signal intensity. The findings may highlight that indeed autophagy control may serve as a promising avenue to promote an improved resection and GBM prognosis.
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Affiliation(s)
- Kim Fredericks
- Department of Physiological Sciences, Stellenbosch University, Stellenbosch, South Africa
| | - Jurgen Kriel
- Central Analytical Facility, Microscopy Unit, Stellenbosch University, South Africa
| | - Lize Engelbrecht
- Central Analytical Facility, Microscopy Unit, Stellenbosch University, South Africa
| | | | - Georg Widhalm
- Department of Neurosurgery, Medical University of Vienna, Vienna, Austria
| | - Brad Harrington
- Department of Neurosurgery, Stellenbosch University, Cape Town, South Africa
| | - Ian Vlok
- Department of Neurosurgery, Stellenbosch University, Cape Town, South Africa
| | - Ben Loos
- Department of Physiological Sciences, Stellenbosch University, Stellenbosch, South Africa
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Ndabakuranye JP, Belcourt J, Sharma D, O'Connell CD, Mondal V, Srivastava SK, Stacey A, Long S, Fleiss B, Ahnood A. Miniature fluorescence sensor for quantitative detection of brain tumour. LAB ON A CHIP 2024; 24:946-954. [PMID: 38275166 DOI: 10.1039/d3lc00982c] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/27/2024]
Abstract
Fluorescence-guided surgery has emerged as a vital tool for tumour resection procedures. As well as intraoperative tumour visualisation, 5-ALA-induced PpIX provides an avenue for quantitative tumour identification based on ratiometric fluorescence measurement. To this end, fluorescence imaging and fibre-based probes have enabled more precise demarcation between the cancerous and healthy tissues. These sensing approaches, which rely on collecting the fluorescence light from the tumour resection site and its "remote" spectral sensing, introduce challenges associated with optical losses. In this work, we demonstrate the viability of tumour detection at the resection site using a miniature fluorescence measurement system. Unlike the current bulky systems, which necessitate remote measurement, we have adopted a millimetre-sized spectral sensor chip for quantitative fluorescence measurements. A reliable measurement at the resection site requires a stable optical window between the tissue and the optoelectronic system. This is achieved using an antifouling diamond window, which provides stable optical transparency. The system achieved a sensitivity of 92.3% and specificity of 98.3% in detecting a surrogate tumour at a resolution of 1 × 1 mm2. As well as addressing losses associated with collecting and coupling fluorescence light in the current 'remote' sensing approaches, the small size of the system introduced in this work paves the way for its direct integration with the tumour resection tools with the aim of more accurate interoperative tumour identification.
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Affiliation(s)
| | | | - Deepak Sharma
- School of Engineering, RMIT University, VIC 3000, Australia.
- Photovoltaic Metrology Section, Advanced Materials and Device Metrology Division, CSIR-National Physical Laboratory, New Delhi, 110012, India
- Academy of Scientific and Innovative Research (AcSIR), Ghaziabad-201002, India
| | - Cathal D O'Connell
- School of Engineering, RMIT University, VIC 3000, Australia.
- Aikenhead Centre for Medical Discovery, St Vincent's Hospital Melbourne, VIC 3065, Australia
| | - Victor Mondal
- School of Health and Biomedical Sciences, RMIT University, VIC 3000, Australia
| | - Sanjay K Srivastava
- Photovoltaic Metrology Section, Advanced Materials and Device Metrology Division, CSIR-National Physical Laboratory, New Delhi, 110012, India
- Academy of Scientific and Innovative Research (AcSIR), Ghaziabad-201002, India
| | - Alastair Stacey
- School of Science, RMIT University, VIC 3000, Australia
- Princeton Plasma Physics Laboratory, Princeton University, Princeton, 08540 New Jersey, USA
| | - Sam Long
- Veterinary Referral Hospital, Victoria, Australia
| | - Bobbi Fleiss
- School of Health and Biomedical Sciences, RMIT University, VIC 3000, Australia
| | - Arman Ahnood
- School of Engineering, RMIT University, VIC 3000, Australia.
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7
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Peters DR, Halimi F, Ozduman K, Levivier M, Conti A, Reyns N, Tuleasca C. Resection of the contrast-enhancing tumor in diffuse gliomas bordering eloquent areas using electrophysiology and 5-ALA fluorescence: evaluation of resection rates and neurological outcome-a systematic review and meta-analysis. Neurosurg Rev 2023; 46:185. [PMID: 37498398 PMCID: PMC10374773 DOI: 10.1007/s10143-023-02064-7] [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: 05/11/2023] [Revised: 06/16/2023] [Accepted: 06/19/2023] [Indexed: 07/28/2023]
Abstract
Independently, both 5-aminolevulinic acid (5-ALA) and intraoperative neuromonitoring (IONM) have been shown to improve outcomes with high-grade gliomas (HGG). The interplay and overlap of both techniques are scarcely reported in the literature. We performed a systematic review and meta-analysis focusing on the concomitant use of 5-ALA and intraoperative mapping for HGG located within eloquent cortex. Using PRISMA guidelines, we reviewed articles published between May 2006 and December 2022 for patients with HGG in eloquent cortex who underwent microsurgical resection using intraoperative mapping and 5-ALA fluorescence guidance. Extent of resection was the primary outcome. The secondary outcome was new neurological deficit at day 1 after surgery and persistent at day 90 after surgery. Overall rate of complete resection of the enhancing tumor (CRET) was 73.3% (range: 61.9-84.8%, p < .001). Complete 5-ALA resection was performed in 62.4% (range: 28.1-96.7%, p < .001). Surgery was stopped due to mapping findings in 20.5% (range: 15.6-25.4%, p < .001). Neurological decline at day 1 after surgery was 29.2% (range: 9.8-48.5%, p = 0.003). Persistent neurological decline at day 90 after surgery was 4.6% (range: 0.4-8.7%, p = 0.03). Maximal safe resection guided by IONM and 5-ALA for high-grade gliomas in eloquent areas is achievable in a high percentage of cases (73.3% CRET and 62.4% complete 5-ALA resection). Persistent neurological decline at postoperative day 90 is as low as 4.6%. A balance between 5-ALA and IONM should be maintained for a better quality of life while maximizing oncological control.
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Affiliation(s)
- David R Peters
- Department of Neurosurgery, Atrium Health, Charlotte, NC, USA.
- Neurosurgery Service and Gamma Knife Center, Lausanne University Hospital (CHUV), Lausanne, Switzerland.
| | - Floriana Halimi
- Neurosurgery Service and Gamma Knife Center, Lausanne University Hospital (CHUV), Lausanne, Switzerland
| | - Koray Ozduman
- Department of Neurosurgery, School of Medicine, Acibadem Mehmet Ali Aydınlar University, Istanbul, Turkey
| | - Marc Levivier
- Neurosurgery Service and Gamma Knife Center, Lausanne University Hospital (CHUV), Lausanne, Switzerland
- Faculty of Biology and Medicine (FBM), University of Lausanne (UNIL), Lausanne, Switzerland
| | - Alfredo Conti
- IRCCS Istituto Delle Scienze Neurologiche Di Bologna, Bologna, Italy
- Dipartimento Di Scienze Biomediche E Neuromotorie (DIBINEM), Alma Mater Studiorum, University of Bologna, Bologna, Italy
| | - Nicolas Reyns
- Neurosurgery and Neurooncology Service, Centre Hospitalier Regional Universitaire de Lille, Roger Salengro Hospital, Lille, France
| | - Constantin Tuleasca
- Neurosurgery Service and Gamma Knife Center, Lausanne University Hospital (CHUV), Lausanne, Switzerland
- Faculty of Biology and Medicine (FBM), University of Lausanne (UNIL), Lausanne, Switzerland
- Ecole Polytechnique Fédérale de Lausanne (EPFL, LTS-5), Lausanne, Switzerland
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8
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Kim HM, Lee MH, Lee TK. Delayed Detection of a 5-Aminolevulinic Acid In Vivo: A Case of Metastatic Breast Cancer. Brain Tumor Res Treat 2023; 11:216-218. [PMID: 37550822 PMCID: PMC10409620 DOI: 10.14791/btrt.2023.0014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2023] [Revised: 05/31/2023] [Accepted: 06/26/2023] [Indexed: 08/09/2023] Open
Abstract
A 44-year-old female patient who had been diagnosed with breast cancer visited our oncology department. She had developed right-side weakness and mild dysarthria, and MRI revealed a 4-cm cystic-enhancing lesion in her left frontal lobe. Her surgery was postponed 48 hours after receiving 5-aminolevulinic acid (5-ALA), because a problem with thyroid function that had not been noticed before was discovered. The main lesion was enhanced on navigation and appeared to be a gross tumor; its 5-ALA uptake was very high. Specimens obtained from this location were histologically confirmed to contain tumor cells. The operation was completed, and removal of all enhancing lesions was confirmed by MRI within 24 hours postoperatively. The pathology report confirmed metastatic ductal carcinoma. The clinical efficacy of 5-ALA was confirmed even 48 hours after administration into a metastatic brain tumor from breast cancer.
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Affiliation(s)
- Hyung Min Kim
- Department of Neurosurgery, Uijeongbu St. Mary's Hospital, School of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Min Ho Lee
- Department of Neurosurgery, Uijeongbu St. Mary's Hospital, School of Medicine, The Catholic University of Korea, Seoul, Korea.
| | - Tae-Kyu Lee
- Department of Neurosurgery, Uijeongbu St. Mary's Hospital, School of Medicine, The Catholic University of Korea, Seoul, Korea
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Belykh E, Bardonova L, Abramov I, Byvaltsev VA, Kerymbayev T, Yu K, Healey DR, Luna-Melendez E, Deneen B, Mehta S, Liu JK, Preul MC. 5-aminolevulinic acid, fluorescein sodium, and indocyanine green for glioma margin detection: analysis of operating wide-field and confocal microscopy in glioma models of various grades. Front Oncol 2023; 13:1156812. [PMID: 37287908 PMCID: PMC10242067 DOI: 10.3389/fonc.2023.1156812] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Accepted: 04/28/2023] [Indexed: 06/09/2023] Open
Abstract
Introduction Surgical resection remains the first-line treatment for gliomas. Several fluorescent dyes are currently in use to augment intraoperative tumor visualization, but information on their comparative effectiveness is lacking. We performed systematic assessment of fluorescein sodium (FNa), 5-aminolevulinic acid (5-ALA)-induced protoporphyrin IX (PpIX), and indocyanine green (ICG) fluorescence in various glioma models using advanced fluorescence imaging techniques. Methods Four glioma models were used: GL261 (high-grade model), GB3 (low-grade model), and an in utero electroporation model with and without red fluorescence protein (IUE +RFP and IUE -RFP, respectively) (intermediate-to-low-grade model). Animals underwent 5-ALA, FNa, and ICG injections and craniectomy. Brain tissue samples underwent fluorescent imaging using a wide-field operative microscope and a benchtop confocal microscope and were submitted for histologic analysis. Results Our systematic analysis showed that wide-field imaging of highly malignant gliomas is equally efficient with 5-ALA, FNa, and ICG, although FNa is associated with more false-positive staining of the normal brain. In low-grade gliomas, wide-field imaging cannot detect ICG staining, can detect FNa in only 50% of specimens, and is not sensitive enough for PpIX detection. With confocal imaging of low-intermediate grade glioma models, PpIX outperformed FNa. Discussion Overall, compared to wide-field imaging, confocal microscopy significantly improved diagnostic accuracy and was better at detecting low concentrations of PpIX and FNa, resulting in improved tumor delineation. Neither PpIX, FNa, nor ICG delineated all tumor boundaries in studied tumor models, which emphasizes the need for novel visualization technologies and molecular probes to guide glioma resection. Simultaneous administration of 5-ALA and FNa with use of cellular-resolution imaging modalities may provide additional information for margin detection and may facilitate maximal glioma resection.
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Affiliation(s)
- Evgenii Belykh
- The Loyal and Edith Davis Neurosurgical Research Laboratory, Department of Neurosurgery, Barrow Neurological Institute, St. Joseph’s Hospital and Medical Center, Phoenix, AZ, United States
- Department of Neurosurgery, New Jersey Medical School, Rutgers University, Newark, NJ, United States
| | - Liudmila Bardonova
- The Loyal and Edith Davis Neurosurgical Research Laboratory, Department of Neurosurgery, Barrow Neurological Institute, St. Joseph’s Hospital and Medical Center, Phoenix, AZ, United States
| | - Irakliy Abramov
- The Loyal and Edith Davis Neurosurgical Research Laboratory, Department of Neurosurgery, Barrow Neurological Institute, St. Joseph’s Hospital and Medical Center, Phoenix, AZ, United States
| | - Vadim A. Byvaltsev
- Department of Neurosurgery, Irkutsk State Medical University, Irkutsk, Russia
| | - Talgat Kerymbayev
- Department of Neurosurgery, JSC “National Scientific Center of Neurosurgery”, Nur-Sultan, Kazakhstan
| | - Kwanha Yu
- Center for Cell and Gene Therapy, Baylor College of Medicine, Houston, TX, United States
| | - Debbie R. Healey
- Department of Research Imaging, Barrow Neurological Institute, St. Joseph’s Hospital and Medical Center, Phoenix, AZ, United States
| | | | - Benjamin Deneen
- Center for Cell and Gene Therapy, Baylor College of Medicine, Houston, TX, United States
| | - Shwetal Mehta
- Ivy Brain Tumor Research Center, Department of Neurosurgery, Barrow Neurological Institute, St. Joseph’s Hospital and Medical Center, Phoenix, AZ, United States
| | - James K. Liu
- Department of Neurosurgery, New Jersey Medical School, Rutgers University, Newark, NJ, United States
| | - Mark C. Preul
- The Loyal and Edith Davis Neurosurgical Research Laboratory, Department of Neurosurgery, Barrow Neurological Institute, St. Joseph’s Hospital and Medical Center, Phoenix, AZ, United States
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10
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Taubenschmid-Stowers J, Orthofer M, Laemmerer A, Krauditsch C, Rózsová M, Studer C, Lötsch D, Gojo J, Gabler L, Dyczynski M, Efferth T, Hagelkruys A, Widhalm G, Peyrl A, Spiegl-Kreinecker S, Hoepfner D, Bian S, Berger W, Knoblich JA, Elling U, Horn M, Penninger JM. A whole-genome scan for Artemisinin cytotoxicity reveals a novel therapy for human brain tumors. EMBO Mol Med 2023; 15:e16959. [PMID: 36740985 DOI: 10.15252/emmm.202216959] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2022] [Revised: 12/14/2022] [Accepted: 12/22/2022] [Indexed: 02/07/2023] Open
Abstract
The natural compound Artemisinin is the most widely used antimalarial drug worldwide. Based on its cytotoxicity, it is also used for anticancer therapy. Artemisinin and its derivates are endoperoxides that damage proteins in eukaryotic cells; their definite mechanism of action and host cell targets, however, have remained largely elusive. Using yeast and haploid stem cell screening, we demonstrate that a single cellular pathway, namely porphyrin (heme) biosynthesis, is required for the cytotoxicity of Artemisinins. Genetic or pharmacological modulation of porphyrin production is sufficient to alter its cytotoxicity in eukaryotic cells. Using multiple model systems of human brain tumor development, such as cerebral glioblastoma organoids, and patient-derived tumor spheroids, we sensitize cancer cells to dihydroartemisinin using the clinically approved porphyrin enhancer and surgical fluorescence marker 5-aminolevulinic acid, 5-ALA. A combination treatment of Artemisinins and 5-ALA markedly and specifically killed brain tumor cells in all model systems tested, including orthotopic patient-derived xenografts in vivo. These data uncover the critical molecular pathway for Artemisinin cytotoxicity and a sensitization strategy to treat different brain tumors, including drug-resistant human glioblastomas.
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Affiliation(s)
- Jasmin Taubenschmid-Stowers
- IMBA, Institute of Molecular Biotechnology of the Austrian Academy of Sciences, Vienna Biocenter, Vienna, Austria
| | | | - Anna Laemmerer
- Center for Cancer Research and Comprehensive Cancer Center-Central Nervous System Tumor Unit, Medical University of Vienna, Vienna, Austria
- Department of Pediatrics and Adolescent Medicine and Comprehensive Center for Pediatrics, Medical University of Vienna, Vienna, Austria
| | - Christian Krauditsch
- IMBA, Institute of Molecular Biotechnology of the Austrian Academy of Sciences, Vienna Biocenter, Vienna, Austria
| | | | | | - Daniela Lötsch
- Center for Cancer Research and Comprehensive Cancer Center-Central Nervous System Tumor Unit, Medical University of Vienna, Vienna, Austria
- Department of Neurosurgery, Medical University Vienna, Vienna, Austria
| | - Johannes Gojo
- Department of Pediatrics and Adolescent Medicine and Comprehensive Center for Pediatrics, Medical University of Vienna, Vienna, Austria
| | - Lisa Gabler
- Center for Cancer Research and Comprehensive Cancer Center-Central Nervous System Tumor Unit, Medical University of Vienna, Vienna, Austria
- Department of Pediatric Oncology, Dana-Farber Boston Children's Cancer and Blood Disorders Center, Boston, MA, USA
- Broad Institute of Harvard and MIT, Cambridge, MA, USA
| | | | - Thomas Efferth
- Department of Pharmaceutical Biology, Institute of Pharmaceutical and Biomedical Sciences, Johannes Gutenberg University, Mainz, Germany
| | - Astrid Hagelkruys
- IMBA, Institute of Molecular Biotechnology of the Austrian Academy of Sciences, Vienna Biocenter, Vienna, Austria
| | - Georg Widhalm
- Department of Neurosurgery, Medical University Vienna, Vienna, Austria
| | - Andreas Peyrl
- Department of Pediatrics and Adolescent Medicine and Comprehensive Center for Pediatrics, Medical University of Vienna, Vienna, Austria
| | - Sabine Spiegl-Kreinecker
- Department of Neurosurgery, Kepler University Hospital GmbH, Johannes Kepler University Linz, Linz, Austria
| | | | - Shan Bian
- IMBA, Institute of Molecular Biotechnology of the Austrian Academy of Sciences, Vienna Biocenter, Vienna, Austria
- Institute for Regenerative Medicine, Shanghai East Hospital, School of Life Sciences and Technology, Tongji University, Shanghai, China
- Frontier Science Center for Stem Cell Research, Tongji University, Shanghai, China
| | - Walter Berger
- Center for Cancer Research and Comprehensive Cancer Center-Central Nervous System Tumor Unit, Medical University of Vienna, Vienna, Austria
| | - Juergen A Knoblich
- IMBA, Institute of Molecular Biotechnology of the Austrian Academy of Sciences, Vienna Biocenter, Vienna, Austria
| | - Ulrich Elling
- IMBA, Institute of Molecular Biotechnology of the Austrian Academy of Sciences, Vienna Biocenter, Vienna, Austria
| | | | - Josef M Penninger
- IMBA, Institute of Molecular Biotechnology of the Austrian Academy of Sciences, Vienna Biocenter, Vienna, Austria
- Department of Medical Genetics, Life Sciences Institute, University of British Columbia, Vancouver, BC, Canada
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11
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Mui OOT, Murray DB, Walsh B, Crimmins DW, Caird JD. Spontaneous intracerebral haemorrhage secondary to 5-ALA-induced thrombocytopaenia in a paediatric patient: case report and literature review. Childs Nerv Syst 2023; 39:1051-1058. [PMID: 36662275 PMCID: PMC10160215 DOI: 10.1007/s00381-023-05846-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2022] [Accepted: 01/10/2023] [Indexed: 01/21/2023]
Abstract
INTRODUCTION The primary objective of neurosurgical management of malignant gliomas is maximal safe resection of the tumour. One of the main obstacles in achieving this is the ability to accurately discriminate between tumour edges and the surrounding healthy brain tissue. The use of fluorescence-guided surgery utilising 5-aminolevulinic acid (5-ALA), first introduced more than 20 years ago, has become an invaluable adjunct in high-grade glioma surgery in adults. However, as 5-ALA is not licensed for use in paediatric patients, the safety profile for such use remains undetermined. CASE REPORT We describe the case of a 4-year-old boy who underwent 5-ALA-guided resection of a fourth ventricle anaplastic ependymoma. Although complete resection was achieved and the patient awoke from surgery well with no neurological deficits, the patient developed acute transaminitis, anaemia, thrombocytopaenia and coagulopathy postoperatively. The patient had a sudden neurological deterioration on postoperative day 2; imaging revealed that he had suffered a spontaneous right frontal intracerebral haemorrhage. The patient returned to theatre for surgical decompression and evacuation of the haematoma, and ultimately went on to make a full recovery. CONCLUSION The use of 5-ALA in paediatric patients can be helpful in maximising surgical resection, but the associated safety profile remains undefined. Further research is urgently warranted in order to characterise the efficacy and risk of the use of 5-ALA in the paediatric population.
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Affiliation(s)
- Olivia O T Mui
- School of Medicine and Medical Science, University College Dublin, Dublin, Ireland. .,Royal College of Surgeons in Ireland, Dublin, Ireland.
| | - Daniel B Murray
- School of Medicine and Medical Science, University College Dublin, Dublin, Ireland.,Royal College of Surgeons in Ireland, Dublin, Ireland.,Temple Street Children's University Hospital, Dublin, Ireland
| | - Bill Walsh
- Temple Street Children's University Hospital, Dublin, Ireland
| | - Darach W Crimmins
- School of Medicine and Medical Science, University College Dublin, Dublin, Ireland.,Royal College of Surgeons in Ireland, Dublin, Ireland.,Temple Street Children's University Hospital, Dublin, Ireland
| | - John D Caird
- Royal College of Surgeons in Ireland, Dublin, Ireland.,Temple Street Children's University Hospital, Dublin, Ireland
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12
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Bowman-Kirigin JA, Desai R, Saunders BT, Wang AZ, Schaettler MO, Liu CJ, Livingstone AJ, Kobayashi DK, Durai V, Kretzer NM, Zipfel GJ, Leuthardt EC, Osbun JW, Chicoine MR, Kim AH, Murphy KM, Johanns TM, Zinselmeyer BH, Dunn GP. The Conventional Dendritic Cell 1 Subset Primes CD8+ T Cells and Traffics Tumor Antigen to Drive Antitumor Immunity in the Brain. Cancer Immunol Res 2023; 11:20-37. [PMID: 36409838 PMCID: PMC10725570 DOI: 10.1158/2326-6066.cir-22-0098] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2022] [Revised: 07/15/2022] [Accepted: 11/17/2022] [Indexed: 11/22/2022]
Abstract
The central nervous system (CNS) antigen-presenting cell (APC) that primes antitumor CD8+ T-cell responses remains undefined. Elsewhere in the body, the conventional dendritic cell 1 (cDC1) performs this role. However, steady-state brain parenchyma cDC1 are extremely rare; cDCs localize to the choroid plexus and dura. Thus, whether the cDC1 play a function in presenting antigen derived from parenchymal sources in the tumor setting remains unknown. Using preclinical glioblastoma (GBM) models and cDC1-deficient mice, we explored the presently unknown role of cDC1 in CNS antitumor immunity. We determined that, in addition to infiltrating the brain tumor parenchyma itself, cDC1 prime neoantigen-specific CD8+ T cells against brain tumors and mediate checkpoint blockade-induced survival benefit. We observed that cDC, including cDC1, isolated from the tumor, the dura, and the CNS-draining cervical lymph nodes harbored a traceable fluorescent tumor antigen. In patient samples, we observed several APC subsets (including the CD141+ cDC1 equivalent) infiltrating glioblastomas, meningiomas, and dura. In these same APC subsets, we identified a tumor-specific fluorescent metabolite of 5-aminolevulinic acid, which fluorescently labeled tumor cells during fluorescence-guided GBM resection. Together, these data elucidate the specialized behavior of cDC1 and suggest that cDC1 play a significant role in CNS antitumor immunity.
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Affiliation(s)
- Jay A. Bowman-Kirigin
- Department of Neurological Surgery, Washington University School of Medicine, St. Louis, MO, USA
- Andrew M and Jane M. Bursky Center for Human Immunology and Immunotherapy Programs, Washington University School of Medicine, St. Louis, MO, USA
- Department of Pathology and Immunology, Washington University School of Medicine, St. Louis, MO, USA
- Brain Tumor Center/Siteman Cancer Center, Washington University School of Medicine, St. Louis, MO, USA
| | - Rupen Desai
- Andrew M and Jane M. Bursky Center for Human Immunology and Immunotherapy Programs, Washington University School of Medicine, St. Louis, MO, USA
- Brain Tumor Center/Siteman Cancer Center, Washington University School of Medicine, St. Louis, MO, USA
| | - Brian T. Saunders
- Department of Pathology and Immunology, Washington University School of Medicine, St. Louis, MO, USA
| | - Anthony Z. Wang
- Department of Neurological Surgery, Washington University School of Medicine, St. Louis, MO, USA
- Andrew M and Jane M. Bursky Center for Human Immunology and Immunotherapy Programs, Washington University School of Medicine, St. Louis, MO, USA
- Department of Pathology and Immunology, Washington University School of Medicine, St. Louis, MO, USA
- Brain Tumor Center/Siteman Cancer Center, Washington University School of Medicine, St. Louis, MO, USA
| | - Maximilian O. Schaettler
- Department of Neurological Surgery, Washington University School of Medicine, St. Louis, MO, USA
- Andrew M and Jane M. Bursky Center for Human Immunology and Immunotherapy Programs, Washington University School of Medicine, St. Louis, MO, USA
- Department of Pathology and Immunology, Washington University School of Medicine, St. Louis, MO, USA
- Brain Tumor Center/Siteman Cancer Center, Washington University School of Medicine, St. Louis, MO, USA
| | - Connor J. Liu
- Department of Neurological Surgery, Washington University School of Medicine, St. Louis, MO, USA
- Andrew M and Jane M. Bursky Center for Human Immunology and Immunotherapy Programs, Washington University School of Medicine, St. Louis, MO, USA
- Brain Tumor Center/Siteman Cancer Center, Washington University School of Medicine, St. Louis, MO, USA
| | | | - Dale K. Kobayashi
- Department of Neurological Surgery, Washington University School of Medicine, St. Louis, MO, USA
- Andrew M and Jane M. Bursky Center for Human Immunology and Immunotherapy Programs, Washington University School of Medicine, St. Louis, MO, USA
- Brain Tumor Center/Siteman Cancer Center, Washington University School of Medicine, St. Louis, MO, USA
| | - Vivek Durai
- Department of Pathology and Immunology, Washington University School of Medicine, St. Louis, MO, USA
| | - Nicole M. Kretzer
- Department of Pathology and Immunology, Washington University School of Medicine, St. Louis, MO, USA
| | - Gregory J. Zipfel
- Andrew M and Jane M. Bursky Center for Human Immunology and Immunotherapy Programs, Washington University School of Medicine, St. Louis, MO, USA
- Brain Tumor Center/Siteman Cancer Center, Washington University School of Medicine, St. Louis, MO, USA
| | - Eric C. Leuthardt
- Andrew M and Jane M. Bursky Center for Human Immunology and Immunotherapy Programs, Washington University School of Medicine, St. Louis, MO, USA
- Brain Tumor Center/Siteman Cancer Center, Washington University School of Medicine, St. Louis, MO, USA
| | - Joshua W. Osbun
- Andrew M and Jane M. Bursky Center for Human Immunology and Immunotherapy Programs, Washington University School of Medicine, St. Louis, MO, USA
- Brain Tumor Center/Siteman Cancer Center, Washington University School of Medicine, St. Louis, MO, USA
| | - Michael R. Chicoine
- Andrew M and Jane M. Bursky Center for Human Immunology and Immunotherapy Programs, Washington University School of Medicine, St. Louis, MO, USA
- Brain Tumor Center/Siteman Cancer Center, Washington University School of Medicine, St. Louis, MO, USA
| | - Albert H. Kim
- Andrew M and Jane M. Bursky Center for Human Immunology and Immunotherapy Programs, Washington University School of Medicine, St. Louis, MO, USA
- Brain Tumor Center/Siteman Cancer Center, Washington University School of Medicine, St. Louis, MO, USA
| | - Kenneth M. Murphy
- Department of Pathology and Immunology, Washington University School of Medicine, St. Louis, MO, USA
| | - Tanner M. Johanns
- Department of Medicine, Washington University School of Medicine, St. Louis, MO, USA
| | - Bernd H. Zinselmeyer
- Department of Pathology and Immunology, Washington University School of Medicine, St. Louis, MO, USA
| | - Gavin P. Dunn
- Department of Neurological Surgery, Washington University School of Medicine, St. Louis, MO, USA
- Andrew M and Jane M. Bursky Center for Human Immunology and Immunotherapy Programs, Washington University School of Medicine, St. Louis, MO, USA
- Brain Tumor Center/Siteman Cancer Center, Washington University School of Medicine, St. Louis, MO, USA
- Current affiliation: Department of Neurosurgery, Massachusetts General Hospital, Boston, MA USA
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13
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Reichert D, Wadiura LI, Erkkilae MT, Gesperger J, Lang A, Roetzer-Pejrimovsky T, Makolli J, Woehrer A, Wilzbach M, Hauger C, Kiesel B, Andreana M, Unterhuber A, Drexler W, Widhalm G, Leitgeb RA. Flavin fluorescence lifetime and autofluorescence optical redox ratio for improved visualization and classification of brain tumors. Front Oncol 2023; 13:1105648. [PMID: 36890834 PMCID: PMC9986542 DOI: 10.3389/fonc.2023.1105648] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2022] [Accepted: 02/07/2023] [Indexed: 02/22/2023] Open
Abstract
Purpose Modern techniques for improved tumor visualization have the aim to maximize the extent of resection during brain tumor surgery and thus improve patient prognosis. Optical imaging of autofluorescence is a powerful and non-invasive tool to monitor metabolic changes and transformation in brain tumors. Cellular redox ratios can be retrieved from fluorescence emitted by the coenzymes reduced nicotinamide adenine dinucleotide (phosphate) (NAD(P)H) and flavin adenine dinucleotide (FAD). Recent studies point out that the influence of flavin mononucleotide (FMN) has been underestimated. Experimental design Fluorescence lifetime imaging and fluorescence spectroscopy were performed through a modified surgical microscope. We acquired 361 flavin fluorescence lifetime (500-580 nm) and fluorescence spectra (430-740 nm) data points on freshly excised different brain tumors: low-grade gliomas (N=17), high-grade gliomas (N=42), meningiomas (N=23), metastases (N=26) and specimens from the non-tumorous brain (N=3). Results Protein-bound FMN fluorescence in brain tumors did increase with a shift toward a more glycolytic metabolism (R=-0.87). This increased the average flavin fluorescence lifetime in tumor entities with respect to the non-tumorous brain. Further, these metrics were characteristic for the different tumor entities and showed promise for machine learning based brain tumor classification. Conclusions Our results shed light on FMN fluorescence in metabolic imaging and outline the potential for supporting the neurosurgeon in visualizing and classifying brain tumor tissue during surgery.
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Affiliation(s)
- David Reichert
- Center for Medical Physics and Biomedical Engineering, Medical University of Vienna, Vienna, Austria.,Christian Doppler Laboratory for Innovative Optical Imaging and its Translation to Medicine (OPTRAMED), Medical University of Vienna, Vienna, Austria
| | - Lisa I Wadiura
- Department of Neurosurgery, General Hospital and Medical University of Vienna, Vienna, Austria
| | - Mikael T Erkkilae
- Center for Medical Physics and Biomedical Engineering, Medical University of Vienna, Vienna, Austria
| | - Johanna Gesperger
- Center for Medical Physics and Biomedical Engineering, Medical University of Vienna, Vienna, Austria.,Division of Neuropathology and Neurochemistry, Department of Neurology, Medical University of Vienna, Vienna, Austria
| | - Alexandra Lang
- Department of Neurosurgery, General Hospital and Medical University of Vienna, Vienna, Austria
| | - Thomas Roetzer-Pejrimovsky
- Division of Neuropathology and Neurochemistry, Department of Neurology, Medical University of Vienna, Vienna, Austria
| | - Jessica Makolli
- Department of Neurosurgery, General Hospital and Medical University of Vienna, Vienna, Austria
| | - Adelheid Woehrer
- Division of Neuropathology and Neurochemistry, Department of Neurology, Medical University of Vienna, Vienna, Austria
| | - Marco Wilzbach
- Advanced Development Microsurgery, Carl Zeiss Meditec AG, Oberkochen, Germany
| | - Christoph Hauger
- Advanced Development Microsurgery, Carl Zeiss Meditec AG, Oberkochen, Germany
| | - Barbara Kiesel
- Department of Neurosurgery, General Hospital and Medical University of Vienna, Vienna, Austria
| | - Marco Andreana
- Center for Medical Physics and Biomedical Engineering, Medical University of Vienna, Vienna, Austria
| | - Angelika Unterhuber
- Center for Medical Physics and Biomedical Engineering, Medical University of Vienna, Vienna, Austria
| | - Wolfgang Drexler
- Center for Medical Physics and Biomedical Engineering, Medical University of Vienna, Vienna, Austria
| | - Georg Widhalm
- Department of Neurosurgery, General Hospital and Medical University of Vienna, Vienna, Austria
| | - Rainer A Leitgeb
- Center for Medical Physics and Biomedical Engineering, Medical University of Vienna, Vienna, Austria.,Christian Doppler Laboratory for Innovative Optical Imaging and its Translation to Medicine (OPTRAMED), Medical University of Vienna, Vienna, Austria
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14
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Advanced Surgical Technologies for Lung Cancer Treatment: Current Status and Perspectives. ENGINEERED REGENERATION 2022. [DOI: 10.1016/j.engreg.2022.12.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
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15
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Review of Intraoperative Adjuncts for Maximal Safe Resection of Gliomas and Its Impact on Outcomes. Cancers (Basel) 2022; 14:cancers14225705. [PMID: 36428797 PMCID: PMC9688206 DOI: 10.3390/cancers14225705] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2022] [Revised: 11/12/2022] [Accepted: 11/18/2022] [Indexed: 11/22/2022] Open
Abstract
Maximal safe resection is the mainstay of treatment in the neurosurgical management of gliomas, and preserving functional integrity is linked to favorable outcomes. How these modalities differ in their effectiveness on the extent of resection (EOR), survival, and complications remains unknown. A systematic literature search was performed with the following inclusion criteria: published between 2005 and 2022, involving brain glioma surgery, and including one or a combination of intraoperative modalities: intraoperative magnetic resonance imaging (iMRI), awake/general anesthesia craniotomy mapping (AC/GA), fluorescence-guided imaging, or combined modalities. Of 525 articles, 464 were excluded and 61 articles were included, involving 5221 glioma patients, 7(11.4%) articles used iMRI, 21(36.8%) used cortical mapping, 15(24.5%) used 5-aminolevulinic acid (5-ALA) or fluorescein sodium, and 18(29.5%) used combined modalities. The heterogeneity in reporting the amount of surgical resection prevented further analysis. Progression-free survival/overall survival (PFS/OS) were reported in 18/61(29.5%) articles, while complications and permanent disability were reported in 38/61(62.2%) articles. The reviewed studies demonstrate that intraoperative adjuncts such as iMRI, AC/GA mapping, fluorescence-guided imaging, and a combination of these modalities improve EOR. However, PFS/OS were underreported. Combining multiple intraoperative modalities seems to have the highest effect compared to each adjunct alone.
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16
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Shah HA, Leskinen S, Khilji H, Narayan V, Ben-Shalom N, D’Amico RS. Utility of 5-ALA for fluorescence-guided resection of brain metastases: a systematic review. J Neurooncol 2022; 160:669-675. [DOI: 10.1007/s11060-022-04188-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2022] [Accepted: 11/01/2022] [Indexed: 11/14/2022]
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17
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McCracken DJ, Schupper AJ, Lakomkin N, Malcolm J, Painton Bray D, Hadjipanayis CG. Turning on the light for brain tumor surgery: A 5-aminolevulinic acid story. Neuro Oncol 2022; 24:S52-S61. [PMID: 36322101 PMCID: PMC9629477 DOI: 10.1093/neuonc/noac191] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
To aid surgeons in more complete and safe resection of brain tumors, adjuvant technologies have been developed to improve visualization of target tissue. Fluorescence-guided surgery relies on the use of fluorophores and specific light wavelengths to better delineate tumor tissue, inflammation, and areas of blood-brain barrier breakdown. 5-aminolevulinic acid (5-ALA), the first fluorophore developed specifically for brain tumors, accumulates within tumor cells, improving visualization of tumors both at the core, and infiltrative margin. Here, we describe the background of how 5-ALA integrated into the modern neurosurgery practice, clinical evidence for the current use of 5-ALA, and future directions for its role in neurosurgical oncology. Maximal safe resection remains the standard of care for most brain tumors. Gross total resection of high-grade gliomas (HGGs) is associated with greater overall survival and progression-free survival (PFS) in comparison to subtotal resection or adjuvant treatment therapies alone.1-3 A major challenge neurosurgeons encounter when resecting infiltrative gliomas is identification of the glioma tumor margin to perform a radical resection while avoiding and preserving eloquent regions of the brain. 5-aminolevulinic acid (5-ALA) remains the only optical-imaging agent approved by the FDA for use in glioma surgery and identification of tumor tissue.4 A multicenter randomized, controlled trial revealed that 5-ALA fluorescence-guided surgery (FGS) almost doubled the extent of tumor resection and also improved 6-month PFS.5 In this review, we will highlight the current evidence for use of 5-ALA FGS in brain tumor surgery, as well as discuss the future directions for its use.
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Affiliation(s)
- David J McCracken
- Department of Neurosurgery, Piedmont Healthcare, Atlanta, Georgia, USA
| | - Alexander J Schupper
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, Mount Sinai Health System, New York, New York, USA
| | - Nikita Lakomkin
- Department of Neurosurgery, Mayo Clinic, Rochester, Minnesota, USA
| | - James Malcolm
- Department of Neurosurgery, Emory University, Atlanta, Georgia, USA
| | | | - Constantinos G Hadjipanayis
- Corresponding Author: Constantinos G. Hadjipanayis, MD, PhD, Mount Sinai Union Square, 10 Union Square East, Suite 5E, New York, NY 10003, USA ()
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18
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Ikeda N, Furuse M, Futamura G, Kimura S, Nonoguchi N, Kawabata S, Kameda M, Yokoyama K, Takami T, Kawanishi M, Kajimoto Y, Kuroiwa T, Wanibuchi M. The Characteristic of Light Sources and Fluorescence in the 3-Dimensional Digital Exoscope "ORBEYE" for 5-Aminolevulinic Acid-Induced Fluorescence-Guided Surgery Compared with a Conventional Microscope. World Neurosurg 2022; 167:e1268-e1274. [PMID: 36087910 DOI: 10.1016/j.wneu.2022.09.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2022] [Accepted: 09/04/2022] [Indexed: 11/20/2022]
Abstract
BACKGROUND The ORBEYE (ORB), an innovative 3-dimensional digital exoscope, is an equipped system for fluorescence-guided surgery with 5-aminolevulinic acid. Therefore, this study aimed to verify the characteristics of fluorescence-guided surgery with 5-aminolevulinic acid and excitation light source with ORB. METHODS The same operative field of glioblastoma was recorded under blue light (BL) excitation using a conventional microscope (MS) and ORB. For in vitro studies, the energy of 405-nm wavelength light in white light and BL modes of each scope was examined in various focal lengths. To examine the degree of photobleaching with BL for each scope, protoporphyrin IX-soaked filter papers were continuously exposed with BL of an MS and ORB, and the video-recorded red fluorescence intensity was analyzed. RESULTS The color tone of tumor-induced red fluorescence was remarkably different under each scope. Furthermore, nonfluorescent normal structures without red fluorescence were well recognized under ORB. The energy of 405-nm wavelength light in BL was significantly higher in ORB than that in an MS, especially in the short focal length. With continuous BL excitation to filter papers, the relative red fluorescence intensity of filter papers was significantly decreased over time in ORB than in an MS. In low protoporphyrin IX concentration, the difference was more significant. CONCLUSIONS With ORB, the good visibility due to BL energy as compared with an MS might improve the surgical manipulation even in BL mode. However, the weak fluorescent tissue and short focal length should be carefully considered because photobleaching might be critical for FGS.
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Affiliation(s)
- Naokado Ikeda
- Department of Neurosurgery and Neuroendovascular surgery, Osaka Medical and Pharmaceutical University, Takatsuki, Osaka, Japan; Department of Neurosurgery, Ijinkai Takeda General Hospital, Fushimi, Kyoto, Japan.
| | - Motomasa Furuse
- Department of Neurosurgery and Neuroendovascular surgery, Osaka Medical and Pharmaceutical University, Takatsuki, Osaka, Japan
| | - Gen Futamura
- Department of Neurosurgery, Dai-ichi Towakai Hospital, Takatsuki, Osaka, Japan
| | - Seigo Kimura
- Department of Neurosurgery and Neuroendovascular surgery, Osaka Medical and Pharmaceutical University, Takatsuki, Osaka, Japan
| | - Naosuke Nonoguchi
- Department of Neurosurgery and Neuroendovascular surgery, Osaka Medical and Pharmaceutical University, Takatsuki, Osaka, Japan
| | - Shinji Kawabata
- Department of Neurosurgery and Neuroendovascular surgery, Osaka Medical and Pharmaceutical University, Takatsuki, Osaka, Japan
| | - Masahiro Kameda
- Department of Neurosurgery and Neuroendovascular surgery, Osaka Medical and Pharmaceutical University, Takatsuki, Osaka, Japan
| | - Kunio Yokoyama
- Department of Neurosurgery, Ijinkai Takeda General Hospital, Fushimi, Kyoto, Japan
| | - Toshihiro Takami
- Department of Neurosurgery and Neuroendovascular surgery, Osaka Medical and Pharmaceutical University, Takatsuki, Osaka, Japan
| | - Masahiro Kawanishi
- Department of Neurosurgery, Ijinkai Takeda General Hospital, Fushimi, Kyoto, Japan
| | - Yoshinaga Kajimoto
- Department of Neurosurgery and Neuroendovascular surgery, Osaka Medical and Pharmaceutical University, Takatsuki, Osaka, Japan
| | - Toshihiko Kuroiwa
- Department of Neurosurgery and Neuroendovascular surgery, Osaka Medical and Pharmaceutical University, Takatsuki, Osaka, Japan; Department of Neurosurgery, Tesseikai Neurosurgical Hospital, Shijonawate, Osaka, Japan
| | - Masahiko Wanibuchi
- Department of Neurosurgery and Neuroendovascular surgery, Osaka Medical and Pharmaceutical University, Takatsuki, Osaka, Japan
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19
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Wide Dissection Trans-Sulcal Approach for Resection of Deep Intra-Axial Lesions in Eloquent Brain Areas. Curr Oncol 2022; 29:7396-7410. [PMID: 36290858 PMCID: PMC9600937 DOI: 10.3390/curroncol29100581] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2022] [Revised: 09/28/2022] [Accepted: 09/29/2022] [Indexed: 11/05/2022] Open
Abstract
Introduction: Resection of intra-axial tumors (IaT) in eloquent brain regions risks major postoperative neurological deficits. Awake craniotomy is often used to navigate these areas; however, some patients are ineligible for awake procedures. The trans-sulcal approach (TScal) was introduced to reduce parenchymal trauma during tumor resection. We report our experiences utilizing TScal for resection of deep IaT located in eloquent areas. Materials and Methods: This is a single-center retrospective analysis of patients who underwent IaT resection in eloquent areas via TScal from January 2013 to April 2021. Seventeen cases were reviewed, and relevant data was collected. Fluorescence-guided surgery with 5-aminolevulinic acid (ALA) and intraoperative ultrasound was performed in some cases. Results: Seventeen patients (10 males, 7 females) averaging 61.2 years-old (range, 21-76) were included in this study. Average length of stay was 4.8 days, and only 2 patients (11.8%) required hospital readmission within 30 days. Gross total resection (GTR) was achieved in 15 patients (88.2%), while subtotal resection occurred in 2 patients (11.8%). Eleven patients (64.7%) reported full resolution of symptoms, 4 patients (23.5%) reported deficit improvement, and 2 patients (11.8%) experienced no change from their preoperative deficits. No patient developed new permanent deficits postoperatively. Discussion: GTR, preoperative deficit reduction, and complications were comparable to awake craniotomy and other TScal studies. Ancillary intraoperative techniques, such as brain mapping, 5-ALA and intraoperative ultrasound, are afforded by TScal to improve resection rates and overall outcomes. Conclusions: TScal can be an option for patients with deep lesions in eloquent areas who are not candidates for awake surgeries.
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Surgical Treatment of Glioblastoma: State-of-the-Art and Future Trends. J Clin Med 2022; 11:jcm11185354. [PMID: 36143001 PMCID: PMC9505564 DOI: 10.3390/jcm11185354] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Revised: 08/17/2022] [Accepted: 08/31/2022] [Indexed: 11/22/2022] Open
Abstract
Glioblastoma (GBM) is a highly aggressive disease and is associated with poor prognosis despite treatment advances in recent years. Surgical resection of tumor remains the main therapeutic option when approaching these patients, especially when combined with adjuvant radiochemotherapy. In the present study, we conducted a comprehensive literature review on the state-of-the-art and future trends of the surgical treatment of GBM, emphasizing topics that have been the object of recent study.
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21
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Sputum analysis by flow cytometry; an effective platform to analyze the lung environment. PLoS One 2022; 17:e0272069. [PMID: 35976857 PMCID: PMC9385012 DOI: 10.1371/journal.pone.0272069] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2022] [Accepted: 07/12/2022] [Indexed: 11/19/2022] Open
Abstract
Low dose computed tomography (LDCT) is the standard of care for lung cancer screening in the United States (US). LDCT has a sensitivity of 93.8% but its specificity of 73.4% leads to potentially harmful follow-up procedures in patients without lung cancer. Thus, there is a need for additional assays with high accuracy that can be used as an adjunct to LDCT to diagnose lung cancer. Sputum is a biological fluid that can be obtained non-invasively and can be dissociated to release its cellular contents, providing a snapshot of the lung environment. We obtained sputum from current and former smokers with a 30+ pack-year smoking history and who were either confirmed to have lung cancer or at high risk of developing the disease. Dissociated sputum cells were counted, viability determined, and labeled with a panel of markers to separate leukocytes from non-leukocytes. After excluding debris and dead cells, including squamous epithelial cells, we identified reproducible population signatures and confirmed the samples’ lung origin. In addition to leukocyte and epithelial-specific fluorescent antibodies, we used the highly fluorescent meso-tetra(4-carboxyphenyl) porphyrin (TCPP), known to preferentially stain cancer (associated) cells. We looked for differences in cell characteristics, population size and fluorescence intensity that could be useful in distinguishing cancer samples from high-risk samples. We present our data demonstrating the feasibility of a flow cytometry platform to analyze sputum in a high-throughput and standardized matter for the diagnosis of lung cancer.
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22
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Solomou G, Gharooni AA, Patel W, Gillespie CS, Gough M, Venkatesh A, Poon MTC, Wykes V, Price SJ, Jenkinson MD, Watts C, Plaha P. Utility of 5-ALA for resection of CNS tumours other than high-grade gliomas: a protocol for a systematic review. BMJ Open 2022; 12:e056059. [PMID: 35868820 PMCID: PMC9315896 DOI: 10.1136/bmjopen-2021-056059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
INTRODUCTION 5-aminolevulinic acid (5-ALA) is a proagent developed for fluorescent-guided surgery for high-grade glioma patients associated with a significant increase in resection conferring survival. 5-ALA was shown to penetrate the blood-brain barrier accumulating in malignant glioma cells with high selectivity, sensitivity and positive predictive value. However, those have yet to be explored aiding diagnosis for tumours of the central nervous system (CNS) other than high-grade gliomas (HGG). No up-to-date systematic review exists reporting the major surgical outcomes and diagnostic accuracy. We sought to conduct a systematic review of the literature summarising surgical outcomes, evaluate the quality of diagnostic accuracy reported in the literature and qualitatively assess the evidence to inform future studies. METHODS AND ANALYSIS We will search electronic databases (Medline, Embase) with subsequent interrogation of references lists of articles reporting the use of 5-ALA for brain tumours other than high-grade glioma adult patients, which also report the extent of resection and/or survival. Prospective and retrospective cohort and case-control studies with more than five patients will be included. Two independent reviewers will screen the abstracts and full articles, with a third reviewer resolving any conflicts. The data will be extracted in a standardised template and outcomes will be reported using descriptive statists. The quality of non-randomised studies will be appraised. ETHICS AND DISSEMINATION The study will summarise the available evidence on the effect of the clinical utility of 5-ALA in achieving resection and improving survival and its diagnostic accuracy for tumours of the CNS other than HGG. The data will be presented nationally and internationally and the manuscript will be published in a peer-reviewed journal. No ethical approvals were needed. The aim is to inform prospective studies minimising reporting bias allowing for more reliable, reproducible and generalisable results. The study has been registered in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines.PROSPERO registration numberCRD42021260542.
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Affiliation(s)
- Georgios Solomou
- School of Clinical Medicine, University of Cambridge, Cambridge, UK
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
| | - Aref-Ali Gharooni
- Department of Clinical Neuroscience, Addenbrooke's Hospital, Cambridge, UK
| | - Waqqas Patel
- Department of Neurosurgery, John Radcliffe Hospital, Oxford, UK
| | - Conor S Gillespie
- Neurosurgery Division, Dept. Clinical Neurosciences, Cambridge University, Cambridge, UK
| | - Melissa Gough
- Department of Neurosurgery, Royal Victoria Infirmary Newcastle Hospitals NHS Trust, Newcastle, UK
| | - Ashwin Venkatesh
- Blizard Institute, Centre for Neuroscience Surgery and Trauma, Barts Health NHS Trust, London, UK
| | - Michael T C Poon
- Usher Institute, University of Edinburgh, Edinburgh, UK
- Department of Clinical Neuroscience, Royal Infirmary Edinburgh, Edinburgh, UK
| | - Victoria Wykes
- University of Birmingham College of Medical and Dental Sciences, Birmingham, UK
- Department of Neurosurgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Stephen John Price
- Neurosurgery Division, Dept. Clinical Neurosciences, Cambridge University, Cambridge, UK
| | - Michael D Jenkinson
- Neurosurgery, The Walton Centre NHS Foundation Trust, Liverpool, UK
- Clinical and Molecular Cancer, University of Liverpool, Liverpool, UK
| | - Colin Watts
- University of Birmingham College of Medical and Dental Sciences, Birmingham, UK
- Department of Neurosurgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Puneet Plaha
- Department of Neurosurgery, John Radcliffe Hospital, Oxford, UK
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Harada Y, Murayama Y, Takamatsu T, Otsuji E, Tanaka H. 5-Aminolevulinic Acid-Induced Protoporphyrin IX Fluorescence Imaging for Tumor Detection: Recent Advances and Challenges. Int J Mol Sci 2022; 23:ijms23126478. [PMID: 35742921 PMCID: PMC9223645 DOI: 10.3390/ijms23126478] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2022] [Revised: 06/02/2022] [Accepted: 06/07/2022] [Indexed: 12/18/2022] Open
Abstract
5-Aminolevulinic acid (5-ALA) is a natural amino acid and a precursor of heme and chlorophyll. Exogenously administered 5-ALA is metabolized into protoporphyrin IX (PpIX). PpIX accumulates in cancer cells because of the low activity of ferrochelatase, an enzyme that metabolizes PpIX to heme. High expression of 5-ALA influx transporters, such as peptide transporters 1/2, in cancer cells also enhances PpIX production. Because PpIX radiates red fluorescence when excited with blue/violet light, 5-ALA has been used for the visualization of various tumors. 5-ALA photodynamic diagnosis (PDD) has been shown to improve the tumor removal rate in high-grade gliomas and non-muscular invasive bladder cancers. However, 5-ALA PDD remains a challenge as a diagnostic method because tissue autofluorescence interferes with PpIX signals in cases where tumors emit only weak signals, and non-tumorous lesions, such as inflammatory sites, tend to emit PpIX fluorescence. Here, we review the current outline of 5-ALA PDD and strategies for improving its diagnostic applicability for tumor detection, focusing on optical techniques and 5-ALA metabolic pathways in both viable and necrotic tumor tissues.
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Affiliation(s)
- Yoshinori Harada
- Department of Pathology and Cell Regulation, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, 465 Kajii-cho Kamigyo-ku, Kyoto 602-8566, Japan;
- Correspondence: ; Tel.: +81-75-251-5322
| | - Yasutoshi Murayama
- Division of Digestive Surgery, Department of Surgery, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, 465 Kajii-cho Kamigyo-ku, Kyoto 602-8566, Japan; (Y.M.); (E.O.)
| | - Tetsuro Takamatsu
- Department of Medical Photonics, Kyoto Prefectural University of Medicine, 465 Kajii-cho Kamigyo-ku, Kyoto 602-8566, Japan;
| | - Eigo Otsuji
- Division of Digestive Surgery, Department of Surgery, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, 465 Kajii-cho Kamigyo-ku, Kyoto 602-8566, Japan; (Y.M.); (E.O.)
| | - Hideo Tanaka
- Department of Pathology and Cell Regulation, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, 465 Kajii-cho Kamigyo-ku, Kyoto 602-8566, Japan;
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Boussedra S, Benoit L, Koual M, Bentivegna E, Nguyen-Xuan HT, Bats AS, Azaïs H. Fluorescence guided surgery to improve peritoneal cytoreduction in epithelial ovarian cancer: A systematic review of available data. Eur J Surg Oncol 2022; 48:1217-1223. [PMID: 35227555 DOI: 10.1016/j.ejso.2022.02.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2021] [Revised: 02/10/2022] [Accepted: 02/17/2022] [Indexed: 11/19/2022] Open
Abstract
During surgery for advanced epithelial ovarian cancer (EOC), the most important prognostic factor is the absence of residual tumor. Invisible microscopic peritoneal metastasis (mPM) are not removed during surgery and can be responsible of peritoneal recurrences. The aim of this current systematic review is to assess the role of fluorescence in evaluating mPM in EOC. We performed a systematic review using bibliographic citations from PubMed, Clinical Trials.gov, Embase, Cochrane Library, and Web of Science databases. MeSH terms for fluorescence, EOC and peritoneal carcinomatosis were combined and not restricted to the English language. The final search was performed on September 1rst, 2021. The primary outcome was to determine the diagnostic accuracy of fluorescence. We also reviewed the different techniques used. Eighty-seven studies were identified. Of these, 10 were included for analysis. The sensitivity and specificity of fluorescence ranged between 66.7-100% and 54.2-100%, respectively. Most importantly, the negative predictive value (NPV) ranged from 90 to 100% Due to the heterogeneity of the studies, no consensus was reached concerning the optimal use of fluorescence in terms of type of dye, type and timing of injection and imager to use. No adverse event was reported. Fluorescence can safely be used in EOC to evaluate mPM with a high NPV. However, a randomized controlled trial is needed to homogenize current practice.
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Affiliation(s)
- Safia Boussedra
- Department of Medical and Surgical Sciences (DIMEC), IRCCS Sant'Orsola-Malpighi, Obstetric and Gynecologic Unit, University of Bologna, Bologna, Italy; Gynecologic and Breast Oncologic Surgery Department, Georges Pompidou European Hospital, APHP. Centre, Université de Paris, Paris, France
| | - Louise Benoit
- Gynecologic and Breast Oncologic Surgery Department, Georges Pompidou European Hospital, APHP. Centre, Université de Paris, Paris, France; INSERM UMR-S 1124, Université de Paris, Centre Universitaire des Saint-Père, Paris, France.
| | - Meriem Koual
- Gynecologic and Breast Oncologic Surgery Department, Georges Pompidou European Hospital, APHP. Centre, Université de Paris, Paris, France; INSERM UMR-S 1124, Université de Paris, Centre Universitaire des Saint-Père, Paris, France
| | - Enrica Bentivegna
- Gynecologic and Breast Oncologic Surgery Department, Georges Pompidou European Hospital, APHP. Centre, Université de Paris, Paris, France
| | - Huyen-Thu Nguyen-Xuan
- Gynecologic and Breast Oncologic Surgery Department, Georges Pompidou European Hospital, APHP. Centre, Université de Paris, Paris, France
| | - Anne-Sophie Bats
- Gynecologic and Breast Oncologic Surgery Department, Georges Pompidou European Hospital, APHP. Centre, Université de Paris, Paris, France; INSERM UMR-S 1147, Université de Paris, Centre de Recherche des Cordeliers, Paris, France
| | - Henri Azaïs
- Gynecologic and Breast Oncologic Surgery Department, Georges Pompidou European Hospital, APHP. Centre, Université de Paris, Paris, France; INSERM UMR-S 1147, Université de Paris, Centre de Recherche des Cordeliers, Paris, France
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Correlation of Intraoperative 5-ALA-Induced Fluorescence Intensity and Preoperative 11C-Methionine PET Uptake in Glioma Surgery. Cancers (Basel) 2022; 14:cancers14061449. [PMID: 35326600 PMCID: PMC8946621 DOI: 10.3390/cancers14061449] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2022] [Revised: 03/01/2022] [Accepted: 03/08/2022] [Indexed: 12/14/2022] Open
Abstract
Simple Summary In malignant brain tumor surgery, precise identification of the tumor is essential. 5-Aminolevulinic acid (5-ALA) labels tumor cells with red fluorescence to facilitate tumor resection. On the other hand, the nuclear medicine imaging technique, positron emission tomography with 11C-methionine (MET-PET), can delineate tumors precisely but is not widely available. This study aimed to determine the correlation between intraoperative 5-ALA-induced fluorescence and preoperative MET-PET signals of gliomas. We quantitatively measured the fluorescence intensity from tumor samples and calculated the MET-PET uptake by the tumor. Our study showed that strong tumor fluorescence correlated with high MET-PET uptake and cellular proliferation. Our findings might be valuable to rapidly provide information on tumor biology at the time of surgery in circumstances where MET-PET is inaccessible. Abstract Background: 5-Aminolevulinic acid (5-ALA) is widely employed to assist fluorescence-guided surgery for malignant brain tumors. Positron emission tomography with 11C-methionine (MET-PET) represents the activity of brain tumors with precise boundaries but is not readily available. We hypothesized that quantitative 5-ALA-induced fluorescence intensity might correlate with MET-PET uptake in gliomas. Methods: Adult patients with supratentorial astrocytic gliomas who underwent preoperative MET-PET and surgical tumor resection using 5-ALA were enrolled in this prospective study. The regional tumor uptake of MET-PET was expressed as the ratio of standardized uptake volume max to that of the normal contralateral frontal lobe. A spectrometric fluorescence detection system measured tumor specimens’ ex vivo fluorescence intensity at 635 nm. Ki-67 index and IDH mutation status were assessed by histopathological analysis. Use of an antiepileptic drug (AED) and contrast enhancement pattern on MRI were also investigated. Results: Thirty-two patients, mostly with Glioblastoma IDH wild type (46.9%) and anaplastic astrocytoma IDH mutant (21.9%), were analyzed. When the fluorescence intensity was ranked into four groups, the strongest fluorescence group exhibited the highest mean MET-PET uptake and Ki-67 index values. When rearranged into fluorescence Visible or Non-visible groups, the Visible group had significantly higher MET-PET uptake and Ki-67 index compared to the Non-visible group. Contrast enhancement on MRI and IDH wild type tumors were more frequent among the Visible group. AED use did not correlate with 5-ALA-induced fluorescence intensity. Conclusions: In astrocytic glioma surgery, visible 5-ALA-induced fluorescence correlated with high MET-PET uptake, along with a high Ki-67 index.
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The Combined Use of 5-ALA and Chlorin e6 Photosensitizers for Fluorescence-Guided Resection and Photodynamic Therapy under Neurophysiological Control for Recurrent Glioblastoma in the Functional Motor Area after Ineffective Use of 5-ALA: Preliminary Results. Bioengineering (Basel) 2022; 9:bioengineering9030104. [PMID: 35324793 PMCID: PMC8945443 DOI: 10.3390/bioengineering9030104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2022] [Revised: 02/25/2022] [Accepted: 03/01/2022] [Indexed: 11/17/2022] Open
Abstract
The treatment of glial brain tumors is an unresolved problem in neurooncology, and all existing methods (tumor resection, chemotherapy, radiotherapy, radiosurgery, fluorescence diagnostics, photodynamic therapy, etc.) are directed toward increasing progression-free survival for patients. Fluorescence diagnostics and photodynamic therapy are promising methods for achieving gross total resection and additional treatment of residual parts of the tumor. However, sometimes the use of one photosensitizer for photodynamic therapy does not help, and the time until tumor relapse barely increases. This translational case report describes the preliminary results of the first combined use of 5-ALA and chlorin e6 photosensitizers for fluorescence-guided resection and photodynamic therapy of glioblastoma, which allowed us to perform total resection of tumor tissue according to magnetic resonance and computed tomography images, remove additional tissue with increased fluorescence intensity without neurophysiological consequences, and perform additional therapy. Two months after surgery, no recurrent tumor and no contrast uptake in the tumor bed were detected. Additionally, the patient had ischemic changes in the access zone and along the periphery and cystic-glial changes in the left parietal lobe.
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Zoli M, Daniele B, Giovanni R, Teresa S, Cesare Z, Giuseppe Maria DP. Young Neurosurgeons and Technology: Survey of Young Neurosurgeons Section of Italian Society of Neurosurgery (SINch). World Neurosurg 2022; 162:e436-e456. [DOI: 10.1016/j.wneu.2022.03.022] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2022] [Revised: 03/05/2022] [Accepted: 03/07/2022] [Indexed: 11/25/2022]
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Mazurek M, Szczepanek D, Orzyłowska A, Rola R. Analysis of Factors Affecting 5-ALA Fluorescence Intensity in Visualizing Glial Tumor Cells-Literature Review. Int J Mol Sci 2022; 23:ijms23020926. [PMID: 35055109 PMCID: PMC8779265 DOI: 10.3390/ijms23020926] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2021] [Revised: 01/11/2022] [Accepted: 01/13/2022] [Indexed: 01/27/2023] Open
Abstract
Glial tumors are one of the most common lesions of the central nervous system. Despite the implementation of appropriate treatment, the prognosis is not successful. As shown in the literature, maximal tumor resection is a key element in improving therapeutic outcome. One of the methods to achieve it is the use of fluorescent intraoperative navigation with 5-aminolevulinic acid. Unfortunately, often the level of fluorescence emitted is not satisfactory, resulting in difficulties in the course of surgery. This article summarizes currently available knowledge regarding differences in the level of emitted fluorescence. It may depend on both the histological type and the genetic profile of the tumor, which is reflected in the activity and expression of enzymes involved in the intracellular metabolism of fluorescent dyes, such as PBGD, FECH, UROS, and ALAS. The transport of 5-aminolevulinic acid and its metabolites across the blood–brain barrier and cell membranes mediated by transporters, such as ABCB6 and ABCG2, is also important. Accompanying therapies, such as antiepileptic drugs or steroids, also have an impact on light emission by tumor cells. Accurate determination of the factors influencing the fluorescence of 5-aminolevulinic acid-treated cells may contribute to the improvement of fluorescence navigation in patients with highly malignant gliomas.
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Turner MA, Lwin TM, Amirfakhri S, Nishino H, Hoffman RM, Yazaki PJ, Bouvet M. The Use of Fluorescent Anti-CEA Antibodies to Label, Resect and Treat Cancers: A Review. Biomolecules 2021; 11:1819. [PMID: 34944463 PMCID: PMC8699160 DOI: 10.3390/biom11121819] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2021] [Revised: 11/21/2021] [Accepted: 11/26/2021] [Indexed: 02/07/2023] Open
Abstract
A major barrier to the diagnosis and effective treatment of solid-tumor cancers is the difficulty in detection and visualization of tumor margins in primary and metastatic disease. The use of fluorescence can augment the surgeon's ability to detect cancer and aid in its resection. Several cancer types express carcinoembryonic antigen (CEA) including colorectal, pancreatic and gastric cancer. Antibodies to CEA have been developed and tagged with near-infrared fluorescent dyes. This review article surveyed the use of CEA antibodies conjugated to fluorescent probes for in vivo studies since 1990. PubMed and Google Scholar databases were queried, and 900 titles and abstracts were screened. Fifty-nine entries were identified as possibly meeting inclusion/exclusion criteria and were reviewed in full. Forty articles were included in the review and their citations were screened for additional entries. A total of 44 articles were included in the final review. The use of fluorescent anti-CEA antibodies has been shown to improve detection and resection of tumors in both murine models and clinically. The cumulative results indicate that fluorescent-conjugated anti-CEA antibodies have important potential to improve cancer diagnosis and surgery. In an emerging technology, anti-CEA fluorescent antibodies have also been successfully used for photoimmunotherapy treatment for cancer.
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Affiliation(s)
- Michael A. Turner
- VA San Diego Healthcare System, La Jolla, CA 92161, USA; (M.A.T.); (S.A.); (H.N.); (R.M.H.)
- Division of Surgical Oncology, Department of Surgery, University of California San Diego, La Jolla, CA 92037, USA
| | | | - Siamak Amirfakhri
- VA San Diego Healthcare System, La Jolla, CA 92161, USA; (M.A.T.); (S.A.); (H.N.); (R.M.H.)
- Division of Surgical Oncology, Department of Surgery, University of California San Diego, La Jolla, CA 92037, USA
| | - Hiroto Nishino
- VA San Diego Healthcare System, La Jolla, CA 92161, USA; (M.A.T.); (S.A.); (H.N.); (R.M.H.)
- Division of Surgical Oncology, Department of Surgery, University of California San Diego, La Jolla, CA 92037, USA
| | - Robert M. Hoffman
- VA San Diego Healthcare System, La Jolla, CA 92161, USA; (M.A.T.); (S.A.); (H.N.); (R.M.H.)
- Division of Surgical Oncology, Department of Surgery, University of California San Diego, La Jolla, CA 92037, USA
- AntiCancer Inc., San Diego, CA 92111, USA
| | - Paul J. Yazaki
- Department of Immunology and Theranostics, Beckman Research Institute, City of Hope, Duarte, CA 91010, USA;
| | - Michael Bouvet
- VA San Diego Healthcare System, La Jolla, CA 92161, USA; (M.A.T.); (S.A.); (H.N.); (R.M.H.)
- Division of Surgical Oncology, Department of Surgery, University of California San Diego, La Jolla, CA 92037, USA
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Schupper AJ, Rao M, Mohammadi N, Baron R, Lee JYK, Acerbi F, Hadjipanayis CG. Fluorescence-Guided Surgery: A Review on Timing and Use in Brain Tumor Surgery. Front Neurol 2021; 12:682151. [PMID: 34220688 PMCID: PMC8245059 DOI: 10.3389/fneur.2021.682151] [Citation(s) in RCA: 34] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Accepted: 05/11/2021] [Indexed: 12/25/2022] Open
Abstract
Fluorescence-guided surgery (FGS) allows surgeons to have improved visualization of tumor tissue in the operating room, enabling maximal safe resection of malignant brain tumors. Over the past two decades, multiple fluorescent agents have been studied for FGS, including 5-aminolevulinic acid (5-ALA), fluorescein sodium, and indocyanine green (ICG). Both non-targeted and targeted fluorescent agents are currently being used in clinical practice, as well as under investigation, for glioma visualization and resection. While the efficacy of intraoperative fluorescence in studied fluorophores has been well established in the literature, the effect of timing on fluorophore administration in glioma surgery has not been as well depicted. In the past year, recent studies of 5-ALA use have shown that intraoperative fluorescence may persist beyond the previously studied window used in prior multicenter trials. Additionally, the use of fluorophores for different brain tumor types is discussed in detail, including a discussion of choosing the right fluorophore based on tumor etiology. In the following review, the authors will describe the temporal nature of the various fluorophores used in glioma surgery, what remains uncertain in FGS, and provide a guide for using fluorescence as a surgical adjunct in brain tumor surgery.
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Affiliation(s)
- Alexander J Schupper
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Manasa Rao
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Nicki Mohammadi
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Rebecca Baron
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - John Y K Lee
- Department of Neurosurgery, University of Pennsylvania School of Medicine, Philadelphia, PA, United States
| | - Francesco Acerbi
- Department of Neurosurgery, Fondazione Istituto Di Ricovero e Cura a Carattere Scientifico Istituto Neurologico Carlo Besta, Milan, Italy
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Ibrahim O, Hafez MA, Haleem HA, El Maghraby H. Recent Advances in the Treatment of Gliomas: The Multimodal Care Therapy. Open Access Maced J Med Sci 2021. [DOI: 10.3889/oamjms.2021.6229] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
BACKGROUND: Glioblastoma (GBM) is the most devastating primary malignancy of the central nervous system in adults. At present, standard treatment consists of maximal safe surgical resection followed by radiotherapy (60 Gray) with concomitant daily temozolomide chemotherapy. Low-grade gliomas constitute approximately 15% of the nearly primary brain tumors diagnosed in adults each year. Extent of tumor resection has become a strong predictor of patient outcomes, alongside patient age, performance status, tumor histology, and molecular genetics (isocitrate dehydrogenase-1 and 1p/19q codeletion status). Over the past two decades, surgeons have emphasized the importance of maximizing extent of resection and its impact on overall survival, progression-free survival, and time to malignant transformation.
AIM: We aimed to present recent advances in the treatment of gliomas.
METHODS: This is a prospective analysis of 50 patients diagnosed with gliomas which are enrolled in a joint supervision between Kasr Al Aini Hospital, Cairo University, Egypt, and Coventry University Hospitals, England.
RESULTS: The study included 50 patients, 31 males and 19 females, ages ranged from 21 to 75 years (mean age 47.5 years). Gross total resection was achieved in 28 patients (56%). The most common surgical complication in our series was post-operative transient weakness in 4 patients (8%). Mean true survival of low-grade glioma patients was 40.5 months while the mean true survival for anaplastic astrocytoma (Grade 3) patients was 38 months and that of GBM (Grade 4) patients was 18.8 months.
CONCLUSION: Despite persistent limitations in the quality of data, mounting evidence suggests that more extensive surgical resection is associated with longer life expectancy for both low- and high-grade gliomas.
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Moin A, Rizvi SMD, Hussain T, Gowda DV, Subaiea GM, Elsayed MMA, Ansari M, Alanazi AS, Yadav H. Current Status of Brain Tumor in the Kingdom of Saudi Arabia and Application of Nanobiotechnology for Its Treatment: A Comprehensive Review. Life (Basel) 2021; 11:421. [PMID: 34063122 PMCID: PMC8148129 DOI: 10.3390/life11050421] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2021] [Revised: 04/27/2021] [Accepted: 04/28/2021] [Indexed: 02/07/2023] Open
Abstract
OBJECTIVE Brain tumors are the most challenging of all tumors and accounts for about 3% of all cancer allied deaths. The aim of the present review is to examine the brain tumor prevalence and treatment modalities available in the Kingdom of Saudi Arabia. It also provides a comprehensive analysis of the application of various nanotechnology-based products for brain cancer treatments along with their prospective future advancements. METHODS A literature review was performed to identify and summarize the current status of brain cancer in Saudi Arabia and the scope of nanobiotechnology in its treatment. RESULTS Depending upon the study population data analysis, gliomas, astrocytoma, meningioma, and metastatic cancer have a higher incidence rate in Saudi Arabia than in other countries, and are mostly treated in accordance with conventional treatment modalities for brain cancer. Due to the poor prognosis of cancer, it has an average survival rate of 2 years. Conventional therapy includes surgery, radiotherapy, chemotherapy, and a combination thereof, but these do not control the disease's recurrence. Among the various nanomaterials discussed, liposomes and polymeric nanoformulations have demonstrated encouraging outcomes for facilitated brain cancer treatment. CONCLUSIONS Nanomaterials possess the capacity to overcome the shortcomings of conventional therapies. Polymer-based nanomaterials have shown encouraging outcomes against brain cancer when amalgamated with other nano-based therapies. Nonetheless, nanomaterials could be devised that possess minimal toxicity towards normal cells or that specifically target tumor cells. In addition, rigorous clinical investigations are warranted to prepare them as an efficient and safe modality for brain cancer therapy.
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Affiliation(s)
- Afrasim Moin
- Department of Pharmaceutics, College of Pharmacy, University of Hail, Hail 81442, Saudi Arabia; (A.M.); (M.M.A.E.)
| | - Syed Mohd Danish Rizvi
- Department of Pharmaceutics, College of Pharmacy, University of Hail, Hail 81442, Saudi Arabia; (A.M.); (M.M.A.E.)
| | - Talib Hussain
- Department of Pharmacology and Toxicology, College of Pharmacy, University of Hail, Hail 81442, Saudi Arabia;
| | - D. V. Gowda
- Department of Pharmaceutics, JSS College of Pharmacy, Mysuru 570015, India;
| | - Gehad M. Subaiea
- Department of Pharmacology and Toxicology, College of Pharmacy, University of Hail, Hail 81442, Saudi Arabia;
| | - Mustafa M. A. Elsayed
- Department of Pharmaceutics, College of Pharmacy, University of Hail, Hail 81442, Saudi Arabia; (A.M.); (M.M.A.E.)
| | - Mukhtar Ansari
- Department of Clinical Pharmacy, College of Pharmacy, University of Hail, Hail 81442, Saudi Arabia; (M.A.); (A.S.A.)
| | - Abulrahman Sattam Alanazi
- Department of Clinical Pharmacy, College of Pharmacy, University of Hail, Hail 81442, Saudi Arabia; (M.A.); (A.S.A.)
| | - Hemant Yadav
- Department of Pharmaceutics, RAK College of Pharmaceutical Sciences, RAK Medical & Health Sciences University, Ras Al Khaimah 11172, United Arab Emirates;
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Darrigues E, Elberson BW, De Loose A, Lee MP, Green E, Benton AM, Sink LG, Scott H, Gokden M, Day JD, Rodriguez A. Brain Tumor Biobank Development for Precision Medicine: Role of the Neurosurgeon. Front Oncol 2021; 11:662260. [PMID: 33981610 PMCID: PMC8108694 DOI: 10.3389/fonc.2021.662260] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2021] [Accepted: 03/29/2021] [Indexed: 12/18/2022] Open
Abstract
Neuro-oncology biobanks are critical for the implementation of a precision medicine program. In this perspective, we review our first year experience of a brain tumor biobank with integrated next generation sequencing. From our experience, we describe the critical role of the neurosurgeon in diagnosis, research, and precision medicine efforts. In the first year of implementation of the biobank, 117 patients (Female: 62; Male: 55) had 125 brain tumor surgeries. 75% of patients had tumors biobanked, and 16% were of minority race/ethnicity. Tumors biobanked were as follows: diffuse gliomas (45%), brain metastases (29%), meningioma (21%), and other (5%). Among biobanked patients, 100% also had next generation sequencing. Eleven patients qualified for targeted therapy based on identification of actionable gene mutations. One patient with a hereditary cancer predisposition syndrome was also identified. An iterative quality improvement process was implemented to streamline the workflow between the operating room, pathology, and the research laboratory. Dedicated tumor bank personnel in the department of neurosurgery greatly improved standard operating procedure. Intraoperative selection and processing of tumor tissue by the neurosurgeon was integral to increasing success with cell culture assays. Currently, our institutional protocol integrates standard histopathological diagnosis, next generation sequencing, and functional assays on surgical specimens to develop precision medicine protocols for our patients. This perspective reviews the critical role of neurosurgeons in brain tumor biobank implementation and success as well as future directions for enhancing precision medicine efforts.
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Affiliation(s)
- Emilie Darrigues
- Winthrop P. Rockefeller Cancer Institute, University of Arkansas for Medical Sciences, Little Rock, AR, United States.,Department of Neurosurgery, University of Arkansas for Medical Sciences, Little Rock, AR, United States
| | - Benjamin W Elberson
- Department of Neurosurgery, University of Arkansas for Medical Sciences, Little Rock, AR, United States
| | - Annick De Loose
- Winthrop P. Rockefeller Cancer Institute, University of Arkansas for Medical Sciences, Little Rock, AR, United States.,Department of Neurosurgery, University of Arkansas for Medical Sciences, Little Rock, AR, United States
| | - Madison P Lee
- Winthrop P. Rockefeller Cancer Institute, University of Arkansas for Medical Sciences, Little Rock, AR, United States.,Department of Neurosurgery, University of Arkansas for Medical Sciences, Little Rock, AR, United States
| | - Ebonye Green
- Department of Neurosurgery, University of Arkansas for Medical Sciences, Little Rock, AR, United States
| | - Ashley M Benton
- Winthrop P. Rockefeller Cancer Institute, University of Arkansas for Medical Sciences, Little Rock, AR, United States
| | - Ladye G Sink
- Winthrop P. Rockefeller Cancer Institute, University of Arkansas for Medical Sciences, Little Rock, AR, United States
| | - Hayden Scott
- Winthrop P. Rockefeller Cancer Institute, University of Arkansas for Medical Sciences, Little Rock, AR, United States
| | - Murat Gokden
- Division of Neuropathology, Department of Pathology, University of Arkansas for Medical Sciences, Little Rock, AR, United States
| | - John D Day
- Department of Neurosurgery, University of Arkansas for Medical Sciences, Little Rock, AR, United States
| | - Analiz Rodriguez
- Winthrop P. Rockefeller Cancer Institute, University of Arkansas for Medical Sciences, Little Rock, AR, United States.,Department of Neurosurgery, University of Arkansas for Medical Sciences, Little Rock, AR, United States
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Baig Mirza A, Christodoulides I, Lavrador JP, Giamouriadis A, Vastani A, Boardman T, Ahmed R, Norman I, Murphy C, Devi S, Vergani F, Gullan R, Bhangoo R, Ashkan K. 5-Aminolevulinic acid-guided resection improves the overall survival of patients with glioblastoma-a comparative cohort study of 343 patients. Neurooncol Adv 2021; 3:vdab047. [PMID: 34131646 PMCID: PMC8193902 DOI: 10.1093/noajnl/vdab047] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Background 5-Aminolevulic acid-guided surgery (5-ALA-GS) improves the extent of resection (EoR) and progression-free survival in patients with glioblastoma multiforme (GBM). Methods A single-center retrospective cohort study of adult patients with GBM who had surgical resection between 2013 and 2019, 5-ALA guided versus a non-5-ALA cohort. The primary outcome was the overall survival (OS). Secondary outcomes were EoR, performance status (PS), and new focal neurological deficit. Results Three hundred and forty-three patients were included: 253 patients in 5-ALA-GS group and 90 patients in the non-5-ALA-GS group. The OS (17.47 vs 10.63 months, P < .0001), postoperative PS (P < .0001), PS at 6 months (P = .002), new focal neurological deficit (23.3% vs 44.9%, P < .0001), and radiological EoR (gross total resection [GTR]-47.4% vs 22.9%, P < .0001) were significantly better in the 5-ALA-GS group compared to non-5-ALA-GS group. In multivariate analysis, use of 5-ALA (P = .003) and MGMT promoter methylation (P = .001) were significantly related with a better OS. In patients with radiological GTR, OS was also significantly better (P < .0001) in the 5-ALA-GS group compared to the non-5-ALA-GS group. Conclusions 5-ALA-GS is associated with a significant improvement in the OS, PS after surgery and at 6 months, larger EoR, and fewer new motor deficits in patients with GBM.
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Affiliation(s)
- Asfand Baig Mirza
- Department of Neurosurgery, King's College Hospital NHS Foundation Trust, London, UK
| | | | - Jose Pedro Lavrador
- Department of Neurosurgery, King's College Hospital NHS Foundation Trust, London, UK
| | | | - Amisha Vastani
- Department of Neurosurgery, King's College Hospital NHS Foundation Trust, London, UK
| | - Timothy Boardman
- GKT School of Medical Education, King's College London, London, UK
| | - Razna Ahmed
- GKT School of Medical Education, King's College London, London, UK
| | - Irena Norman
- GKT School of Medical Education, King's College London, London, UK
| | - Christopher Murphy
- Department of Neurosurgery, King's College Hospital NHS Foundation Trust, London, UK
| | - Sharmila Devi
- GKT School of Medical Education, King's College London, London, UK
| | - Francesco Vergani
- Department of Neurosurgery, King's College Hospital NHS Foundation Trust, London, UK
| | - Richard Gullan
- Department of Neurosurgery, King's College Hospital NHS Foundation Trust, London, UK
| | - Ranjeev Bhangoo
- Department of Neurosurgery, King's College Hospital NHS Foundation Trust, London, UK
| | - Keyoumars Ashkan
- Department of Neurosurgery, King's College Hospital NHS Foundation Trust, London, UK
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Horgan CC, Bergholt MS, Thin MZ, Nagelkerke A, Kennedy R, Kalber TL, Stuckey DJ, Stevens MM. Image-guided Raman spectroscopy probe-tracking for tumor margin delineation. JOURNAL OF BIOMEDICAL OPTICS 2021; 26:JBO-200321R. [PMID: 33715315 PMCID: PMC7960531 DOI: 10.1117/1.jbo.26.3.036002] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/07/2020] [Accepted: 02/17/2021] [Indexed: 06/01/2023]
Abstract
SIGNIFICANCE Tumor detection and margin delineation are essential for successful tumor resection. However, postsurgical positive margin rates remain high for many cancers. Raman spectroscopy has shown promise as a highly accurate clinical spectroscopic diagnostic modality, but its margin delineation capabilities are severely limited by the need for pointwise application. AIM We aim to extend Raman spectroscopic diagnostics and develop a multimodal computer vision-based diagnostic system capable of both the detection and identification of suspicious lesions and the precise delineation of disease margins. APPROACH We first apply visual tracking of a Raman spectroscopic probe to achieve real-time tumor margin delineation. We then combine this system with protoporphyrin IX fluorescence imaging to achieve fluorescence-guided Raman spectroscopic margin delineation. RESULTS Our system enables real-time Raman spectroscopic tumor margin delineation for both ex vivo human tumor biopsies and an in vivo tumor xenograft mouse model. We then further demonstrate that the addition of protoporphyrin IX fluorescence imaging enables fluorescence-guided Raman spectroscopic margin delineation in a tissue phantom model. CONCLUSIONS Our image-guided Raman spectroscopic probe-tracking system enables tumor margin delineation and is compatible with both white light and fluorescence image guidance, demonstrating the potential for our system to be developed toward clinical tumor resection surgeries.
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Affiliation(s)
- Conor C. Horgan
- Imperial College London, Department of Materials, London, United Kingdom
- Imperial College London, Department of Bioengineering, London, United Kingdom
- Imperial College London, Institute of Biomedical Engineering, London, United Kingdom
| | - Mads S. Bergholt
- Imperial College London, Department of Materials, London, United Kingdom
- Imperial College London, Department of Bioengineering, London, United Kingdom
- Imperial College London, Institute of Biomedical Engineering, London, United Kingdom
| | - May Zaw Thin
- University College London, Centre for Advanced Biomedical Imaging, London, United Kingdom
| | - Anika Nagelkerke
- Imperial College London, Department of Materials, London, United Kingdom
- Imperial College London, Department of Bioengineering, London, United Kingdom
- Imperial College London, Institute of Biomedical Engineering, London, United Kingdom
| | - Robert Kennedy
- King’s College London, Guy’s and St Thomas’ NHS Foundation Trust, Oral/Head and Neck Pathology Laboratory, London, United Kingdom
| | - Tammy L. Kalber
- University College London, Centre for Advanced Biomedical Imaging, London, United Kingdom
| | - Daniel J. Stuckey
- University College London, Centre for Advanced Biomedical Imaging, London, United Kingdom
| | - Molly M. Stevens
- Imperial College London, Department of Materials, London, United Kingdom
- Imperial College London, Department of Bioengineering, London, United Kingdom
- Imperial College London, Institute of Biomedical Engineering, London, United Kingdom
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Costa PC, Guang Z, Ledwig P, Zhang Z, Neill S, Olson JJ, Robles FE. Towards in-vivo label-free detection of brain tumor margins with epi-illumination tomographic quantitative phase imaging. BIOMEDICAL OPTICS EXPRESS 2021; 12:1621-1634. [PMID: 33796377 PMCID: PMC7984798 DOI: 10.1364/boe.416731] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/03/2020] [Revised: 02/11/2021] [Accepted: 02/20/2021] [Indexed: 05/03/2023]
Abstract
Brain tumor surgery involves a delicate balance between maximizing the extent of tumor resection while minimizing damage to healthy brain tissue that is vital for neurological function. However, differentiating between tumor, particularly infiltrative disease, and healthy brain in-vivo remains a significant clinical challenge. Here we demonstrate that quantitative oblique back illumination microscopy (qOBM)-a novel label-free optical imaging technique that achieves tomographic quantitative phase imaging in thick scattering samples-clearly differentiates between healthy brain tissue and tumor, including infiltrative disease. Data from a bulk and infiltrative brain tumor animal model show that qOBM enables quantitative phase imaging of thick fresh brain tissues with remarkable cellular and subcellular detail that closely resembles histopathology using hematoxylin and eosin (H&E) stained fixed tissue sections, the gold standard for cancer detection. Quantitative biophysical features are also extracted from qOBM which yield robust surrogate biomarkers of disease that enable (1) automated tumor and margin detection with high sensitivity and specificity and (2) facile visualization of tumor regions. Finally, we develop a low-cost, flexible, fiber-based handheld qOBM device which brings this technology one step closer to in-vivo clinical use. This work has significant implications for guiding neurosurgery by paving the way for a tool that delivers real-time, label-free, in-vivo brain tumor margin detection.
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Affiliation(s)
- Paloma Casteleiro Costa
- School of Electrical and Computer Engineering, Georgia Institute of Technology, Atlanta, GA 30332, USA
| | - Zhe Guang
- Wallace H. Coulter Department of Biomedical Engineering, Georgia Institute of Technology and Emory University, Atlanta, GA 30332, USA
| | - Patrick Ledwig
- Wallace H. Coulter Department of Biomedical Engineering, Georgia Institute of Technology and Emory University, Atlanta, GA 30332, USA
| | - Zhaobin Zhang
- Winship Cancer Institute, Emory University, Atlanta, GA 30322, USA
- Department of Neurosurgery, Emory University School of Medicine, Atlanta, GA 30322, USA
| | - Stewart Neill
- Winship Cancer Institute, Emory University, Atlanta, GA 30322, USA
- Department of Pathology & Laboratory Medicine, Emory University School of Medicine, Atlanta, GA 30322, USA
| | - Jeffrey J. Olson
- Winship Cancer Institute, Emory University, Atlanta, GA 30322, USA
- Department of Neurosurgery, Emory University School of Medicine, Atlanta, GA 30322, USA
| | - Francisco E. Robles
- School of Electrical and Computer Engineering, Georgia Institute of Technology, Atlanta, GA 30332, USA
- Wallace H. Coulter Department of Biomedical Engineering, Georgia Institute of Technology and Emory University, Atlanta, GA 30332, USA
- Winship Cancer Institute, Emory University, Atlanta, GA 30322, USA
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Golub D, Hyde J, Dogra S, Nicholson J, Kirkwood KA, Gohel P, Loftus S, Schwartz TH. Intraoperative MRI versus 5-ALA in high-grade glioma resection: a network meta-analysis. J Neurosurg 2021; 134:484-498. [PMID: 32084631 DOI: 10.3171/2019.12.jns191203] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2019] [Accepted: 12/16/2019] [Indexed: 11/06/2022]
Abstract
OBJECTIVE High-grade gliomas (HGGs) continue to carry poor prognoses, and patient outcomes depend heavily on the extent of resection (EOR). The utility of conventional image-guided surgery is limited by intraoperative brain shift. More recent techniques to maximize EOR, including intraoperative imaging and the use of fluorescent dyes, combat these limitations. However, the relative efficacy of these two techniques has never been systematically compared. Thus, the authors performed an exhaustive systematic review in conjunction with quantitative network meta-analyses to evaluate the comparative effectiveness of 5-aminolevulinic acid (5-ALA) and intraoperative MRI (IMRI) in optimizing EOR in HGG. They secondarily analyzed associated progression-free and overall survival and performed subgroup analyses by level of evidence. METHODS PubMed, Embase, Cochrane Central, and Web of Science were searched for studies evaluating conventional neuronavigation, IMRI, and 5-ALA in HGG resection. The primary study endpoint was the proportion of patients attaining gross-total resection (GTR), defined as 100% elimination of contrast-enhancing lesion on postoperative MRI. Secondary endpoints included overall and progression-free survival and subgroup analyses for level of evidence. Comparative efficacy analysis of IMRI and 5-ALA was performed using Bayesian network meta-analysis models. RESULTS This analysis included 11 studies. In a classic meta-analysis, both IMRI (OR 4.99, 95% CI 2.65-9.39, p < 0.001) and 5-ALA (OR 2.866, 95% CI 2.127-3.863, p < 0.001) were superior to conventional navigation in achieving GTR. Bayesian network analysis was employed to indirectly compare IMRI to 5-ALA, and no significant difference in GTR was found between the two (OR 1.9 favoring IMRI, 95% CI 0.905-3.989, p = 0.090). A handful of studies additionally suggested that the use of either IMRI (2 and 4 studies, respectively) or 5-ALA (2 and 2 studies, respectively) improves progression-free and overall survival. CONCLUSIONS IMRI and 5-ALA are individually superior to conventional neuronavigation for achieving GTR of HGG. Between IMRI and 5-ALA, neither method is clearly more effective. Future studies evaluating the comparative cost and surgical time associated with IMRI and 5-ALA will better inform any cost-benefit analysis.
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Affiliation(s)
| | | | - Siddhant Dogra
- 2Radiology, New York University School of Medicine, New York, New York
| | - Joseph Nicholson
- 3NYU Health Sciences Library, New York University School of Medicine, New York, New York
| | - Katherine A Kirkwood
- 4Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, New York
| | | | - Stephen Loftus
- 5Department of Science, Technology, Engineering and Math, Sweet Briar College, Sweet Briar, Virginia
| | - Theodore H Schwartz
- 6Departments of Neurosurgery, Otolaryngology, and Neuroscience, Weill Cornell Medicine, NewYork-Presbyterian Hospital, New York, New York; and
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Gómez-Oliva R, Domínguez-García S, Carrascal L, Abalos-Martínez J, Pardillo-Díaz R, Verástegui C, Castro C, Nunez-Abades P, Geribaldi-Doldán N. Evolution of Experimental Models in the Study of Glioblastoma: Toward Finding Efficient Treatments. Front Oncol 2021; 10:614295. [PMID: 33585240 PMCID: PMC7878535 DOI: 10.3389/fonc.2020.614295] [Citation(s) in RCA: 40] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2020] [Accepted: 12/14/2020] [Indexed: 12/15/2022] Open
Abstract
Glioblastoma (GBM) is the most common form of brain tumor characterized by its resistance to conventional therapies, including temozolomide, the most widely used chemotherapeutic agent in the treatment of GBM. Within the tumor, the presence of glioma stem cells (GSC) seems to be the reason for drug resistance. The discovery of GSC has boosted the search for new experimental models to study GBM, which allow the development of new GBM treatments targeting these cells. In here, we describe different strategies currently in use to study GBM. Initial GBM investigations were focused in the development of xenograft assays. Thereafter, techniques advanced to dissociate tumor cells into single-cell suspensions, which generate aggregates referred to as neurospheres, thus facilitating their selective expansion. Concomitantly, the finding of genes involved in the initiation and progression of GBM tumors, led to the generation of mice models for the GBM. The latest advances have been the use of GBM organoids or 3D-bioprinted mini-brains. 3D bio-printing mimics tissue cytoarchitecture by combining different types of cells interacting with each other and with extracellular matrix components. These in vivo models faithfully replicate human diseases in which the effect of new drugs can easily be tested. Based on recent data from human glioblastoma, this review critically evaluates the different experimental models used in the study of GB, including cell cultures, mouse models, brain organoids, and 3D bioprinting focusing in the advantages and disadvantages of each approach to understand the mechanisms involved in the progression and treatment response of this devastating disease.
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Affiliation(s)
- Ricardo Gómez-Oliva
- Área de Fisiología, Facultad de Medicina, Universidad de Cádiz, Cádiz, Spain.,Instituto de Investigación e Innovación Biomédica de Cádiz (INIBICA), Cádiz, Spain
| | - Samuel Domínguez-García
- Área de Fisiología, Facultad de Medicina, Universidad de Cádiz, Cádiz, Spain.,Instituto de Investigación e Innovación Biomédica de Cádiz (INIBICA), Cádiz, Spain
| | - Livia Carrascal
- Instituto de Investigación e Innovación Biomédica de Cádiz (INIBICA), Cádiz, Spain.,Departamento de Fisiología, Facultad de Farmacia, Universidad de Sevilla, Sevilla, Spain
| | | | - Ricardo Pardillo-Díaz
- Área de Fisiología, Facultad de Medicina, Universidad de Cádiz, Cádiz, Spain.,Instituto de Investigación e Innovación Biomédica de Cádiz (INIBICA), Cádiz, Spain
| | - Cristina Verástegui
- Instituto de Investigación e Innovación Biomédica de Cádiz (INIBICA), Cádiz, Spain.,Departamento de Anatomía y Embriología Humanas, Facultad de Medicina, Universidad de Cádiz, Cádiz, Spain
| | - Carmen Castro
- Área de Fisiología, Facultad de Medicina, Universidad de Cádiz, Cádiz, Spain.,Instituto de Investigación e Innovación Biomédica de Cádiz (INIBICA), Cádiz, Spain
| | - Pedro Nunez-Abades
- Instituto de Investigación e Innovación Biomédica de Cádiz (INIBICA), Cádiz, Spain.,Departamento de Fisiología, Facultad de Farmacia, Universidad de Sevilla, Sevilla, Spain
| | - Noelia Geribaldi-Doldán
- Departamento de Anatomía y Embriología Humanas, Facultad de Medicina, Universidad de Cádiz, Cádiz, Spain.,Instituto de Investigación e Innovación Biomédica de Cádiz (INIBICA), Cádiz, Spain
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Adhikari M, Adhikari B, Adhikari A, Yan D, Soni V, Sherman J, Keidar M. Cold Atmospheric Plasma as a Novel Therapeutic Tool for the Treatment of Brain Cancer. Curr Pharm Des 2020; 26:2195-2206. [PMID: 32116185 DOI: 10.2174/1381612826666200302105715] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2019] [Accepted: 02/04/2020] [Indexed: 12/15/2022]
Abstract
BACKGROUND Studies from the past few years revealed the importance of Cold Atmospheric Plasma (CAP) on various kinds of diseases, including brain cancers or glioblastoma (GBM), and hence coined a new term 'Plasma Medicine' in the modern world for promising therapeutic approaches. Here, we focus on the efficacy of CAP and its liquid derivatives on direct interactions or with specific nanoparticles to show pivotal roles in brain cancer treatment. METHOD In the present review study, the authors studied several articles over the past decades published on the types of CAP and its effects on different brain cancers and therapy. RESULTS A growing body of evidence indicates that CAP and its derivatives like Plasma Activated Media/ Water (PAM/PAW) are introduced in different kinds of GBM. Recent studies proposed that CAP plays a remarkable role in GBM treatment. To increase the efficacy of CAP, various nanoparticles of different origins got specific attention in recent times. In this review, different strategies to treat brain cancers, including nanoparticles, are discussed as enhancers of CAP induced targeted nanotherapeutic approach. CONCLUSION CAP treatment and its synergistic effects with different nanoparticles hold great promise for clinical applications in early diagnosis and treatment of GBM treatment. However, results obtained from previous studies were still in the preliminary phase, and there must be a concern over the use of optimal methods for a dosage of CAP and nanoparticles for complete cure of GBM.
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Affiliation(s)
- Manish Adhikari
- Department of Mechanical and Aerospace Engineering, The George Washington University, Science & Engineering Hall, 800 22nd Street, NW, Washington, DC, 20052, United States
| | - Bhawana Adhikari
- Plasma Bioscience Research Center, Applied Plasma Medicine Center, Department of Electrical and Biological Physics, Kwangwoon University, Seoul, 01897, Korea
| | - Anupriya Adhikari
- Department of Chemistry, Babasaheb Bhimrao Ambedkar University, Lucknow, 226025, India
| | - Dayun Yan
- Department of Mechanical and Aerospace Engineering, The George Washington University, Science & Engineering Hall, 800 22nd Street, NW, Washington, DC, 20052, United States
| | - Vikas Soni
- Department of Mechanical and Aerospace Engineering, The George Washington University, Science & Engineering Hall, 800 22nd Street, NW, Washington, DC, 20052, United States
| | - Jonathan Sherman
- Neurological Surgery, The George Washington University, Foggy Bottom South Pavilion, 22nd Street, NW, 7th Floor, Washington, DC, 20037, United States
| | - Michael Keidar
- Department of Mechanical and Aerospace Engineering, The George Washington University, Science & Engineering Hall, 800 22nd Street, NW, Washington, DC, 20052, United States
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Mazurek M, Kulesza B, Stoma F, Osuchowski J, Mańdziuk S, Rola R. Characteristics of Fluorescent Intraoperative Dyes Helpful in Gross Total Resection of High-Grade Gliomas-A Systematic Review. Diagnostics (Basel) 2020; 10:E1100. [PMID: 33339439 PMCID: PMC7766001 DOI: 10.3390/diagnostics10121100] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2020] [Revised: 12/10/2020] [Accepted: 12/11/2020] [Indexed: 12/12/2022] Open
Abstract
Background: A very important aspect in the treatment of high-grade glioma is gross total resection to reduce the risk of tumor recurrence. One of the methods to facilitate this task is intraoperative fluorescence navigation. The aim of the study was to compare the dyes used in this technique fluorescent intraoperative navigation in terms of the mechanism of action and influence on the treatment of patients. Methods: The review was carried out on the basis of articles found in PubMed, Google Scholar, and BMC search engines, as well as those identified by searched bibliographies and suggested by experts during the preparation of the article. The database analysis was performed for the following phrases: "glioma", "glioblastoma", "ALA", "5ALA", "5-ALA", "aminolevulinic acid", "levulinic acid", "fluorescein", "ICG", "indocyanine green", and "fluorescence navigation". Results: After analyzing 913 citations identified on the basis of the search criteria, we included 36 studies in the review. On the basis of the analyzed articles, we found that 5-aminolevulinic acid and fluorescein are highly effective in improving the percentage of gross total resection achieved in high-grade glioma surgery. At the same time, the limitations resulting from the use of these methods are marked-higher costs of the procedure and the need to have neurosurgical microscope in combination with a special light filter in the case of 5-aminolevulinic acid (5-ALA), and low specificity for neoplastic cells and the dependence on the degree of damage to the blood-brain barrier in the intensity of fluorescence in the case of fluorescein. The use of indocyanine green in the visualization of glioma cells is relatively unknown, but some researchers have suggested its utility and the benefits of using it simultaneously with other dyes. Conclusion: The use of intraoperative fluorescence navigation with the use of 5-aminolevulinic acid and fluorescein allows the range of high-grade glioma resection to be increased.
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Affiliation(s)
- Marek Mazurek
- Chair and Department of Neurosurgery and Pediatric Neurosurgery, Medical University of Lublin, 20-954 Lublin, Poland; (F.S.); (J.O.); (R.R.)
| | - Bartłomiej Kulesza
- Chair and Department of Neurosurgery and Pediatric Neurosurgery, Medical University of Lublin, 20-954 Lublin, Poland; (F.S.); (J.O.); (R.R.)
| | - Filip Stoma
- Chair and Department of Neurosurgery and Pediatric Neurosurgery, Medical University of Lublin, 20-954 Lublin, Poland; (F.S.); (J.O.); (R.R.)
| | - Jacek Osuchowski
- Chair and Department of Neurosurgery and Pediatric Neurosurgery, Medical University of Lublin, 20-954 Lublin, Poland; (F.S.); (J.O.); (R.R.)
| | - Sławomir Mańdziuk
- Department of Clinical Oncology and Chemotherapy, Medical University of Lublin, 20-954 Lublin, Poland;
| | - Radosław Rola
- Chair and Department of Neurosurgery and Pediatric Neurosurgery, Medical University of Lublin, 20-954 Lublin, Poland; (F.S.); (J.O.); (R.R.)
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Abstract
Fluorescence-guided surgery provides surgeons with improved visualization of tumor tissue in the operating room to allow for maximal safe resection of brain tumors. Multiple fluorescent agents have been studied for fluorescence-guided surgery. Both nontargeted and targeted fluorescent agents are currently being used for glioblastoma multiforme visualization and resection. Fluorescence detection in the visible light or near infrared spectrum is possible. Visualization device advancements have permitted greater detection of fluorescence down to the cellular level, which may provide even greater ability for the neurosurgeon to resect tumors.
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Affiliation(s)
- Alexander J Schupper
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, Mount Sinai Health System, New York, NY, USA
| | - Constantinos Hadjipanayis
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, Mount Sinai Health System, New York, NY, USA; Department of Neurosurgery, Mount Sinai Beth Israel, New York, NY, USA.
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Warsi NM, Zewude R, Karmur B, Pirouzmand N, Hachem L, Mansouri A. The Cost-Effectiveness of 5-ALA in High-Grade Glioma Surgery: A Quality-Based Systematic Review. Can J Neurol Sci 2020; 47:793-799. [PMID: 32329422 DOI: 10.1017/cjn.2020.78] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND High-grade gliomas (HGGs) are aggressive tumors that inevitably recur due to their diffusely infiltrative nature. Intraoperative adjuncts such as 5-aminolevulinic acid (5-ALA) have shown promise in increasing extent of resection. As the prospect of increased use of 5-ALA rises, a systematic overview of the health economics of this adjunct is critical. METHODS Medline, EMBASE, Centre for Reviews and Dissemination, EconPapers, and Cochrane databases were searched for keywords relating to glioma, cost-effectiveness, and 5-ALA. Primary studies reporting on the health economics or cost-effectiveness of 5-ALA compared to white light surgery in HGG were included. Quality was assessed using the British Medical Journal guidelines. RESULTS Three studies were identified. All were European and conducted from the perspective of national healthcare systems. Two studies demonstrated the cost-utility of 5-ALA compared to white light (C$12,817 and C$13,508/quality-adjusted life-years (QALYs)). One assessed the cost-utility per gross total resection (C$6,813). Both these values were below the national cost-effectiveness thresholds for each respective study. The third study demonstrated no significant difference in cost of 5-ALA in glioblastoma resection (C$14,732) compared to prior to its routine use (C$15,936). The quality of these studies ranged from moderate to average. None of these studies considered patient perspective or indirect costs in their analysis. CONCLUSIONS Growing evidence exists examining the health economic benefit of 5-ALA as an intraoperative adjunct for HGG resection. Additional studies within the Canadian context using 5-ALA, specifically incorporating patient and societal perspectives into the cost-utility analyses, are necessary to solidify this line of evidence.
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Affiliation(s)
- Nebras M Warsi
- Division of Neurosurgery, University of Toronto, Toronto, Ontario, Canada
| | - Rahel Zewude
- Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Brij Karmur
- Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Neda Pirouzmand
- Faculty of Health Sciences, McMaster University, Hamilton, ON, Canada
| | - Laureen Hachem
- Division of Neurosurgery, University of Toronto, Toronto, Ontario, Canada
| | - Alireza Mansouri
- Division of Neurosurgery, University of Toronto, Toronto, Ontario, Canada
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Ghinda DC, Yang Y, Wu S, Lu J, Su L, Damiani S, Tumati S, Jansen G, Duffau H, Wu JS, Northoff G. Personalized Multimodal Demarcation of Peritumoral Tissue in Glioma. JCO Precis Oncol 2020; 4:1128-1140. [PMID: 35050774 DOI: 10.1200/po.20.00115] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
PURPOSE Gliomas are life-threatening brain tumors, and the extent of surgical resection is one of the strongest influences on survival rate. However, the proper distinction of infiltrated tissue remains elusive. The aim of this study was to use multimodal analyses to demarcate peritumoral tissue (PT) from tumoral (TT) and healthy tissue (HT). METHODS A total of 40 patients with histologically confirmed glioma were recruited. We analyzed resting-state functional magnetic resonance imaging (rs-fMRI) using the voxel-based mean blood-oxygen-level-dependent (BOLD) signal and the corresponding structural MRI (s-MRI) alongside RNA sequencing, whole-exome sequencing, and histology results of biopsy samples obtained from PT, HT, and TT. RESULTS We demarcated a functionally defined PT area where the mean BOLD signal gradually decreased near the edge of the tumor and extended beyond the TT borders (as defined by s-MRI), which was confirmed on a case-by-case basis. Correspondingly, genetic analyses showed a gene expression pattern and mutational landscape of the PT that were distinct from that seen in HT and TT. The genetic characterization of PT relative to HT and TT converged with the MRI-defined PT zones. This was confirmed in three individual cases after additional histologic analysis. A wider PT was associated with a longer progression-free survival, which suggests PT might act as an intermediate area between TT and HT. CONCLUSION Combined multimodal imaging and genetic analyses can allow for an objective demarcation of the PT in glioma and a robust classification of the degree of infiltration of the PT. These findings could help improve both neurosurgical resection and radio-oncologic therapy.
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Affiliation(s)
- Diana C Ghinda
- Department of Neurosurgery, The Ottawa Hospital, University of Ottawa, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada.,Glioma Surgery Division, Neurologic Surgery Department, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China.,Mind, Brain Imaging, and Neuroethics, Institute of Mental Health Research, University of Ottawa, Ottawa, Ontario, Canada
| | - Yufei Yang
- Genetron Health (Beijing) Co Ltd, Beijing, China
| | - Shuai Wu
- Glioma Surgery Division, Neurologic Surgery Department, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China
| | - Junfeng Lu
- Glioma Surgery Division, Neurologic Surgery Department, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China
| | - Lan Su
- Genetron Health (Beijing) Co Ltd, Beijing, China
| | - Stefano Damiani
- Department of Brain and Behavioral Science, University of Pavia, Pavia, Italy
| | - Shankar Tumati
- Mind, Brain Imaging, and Neuroethics, Institute of Mental Health Research, University of Ottawa, Ottawa, Ontario, Canada
| | - Gerard Jansen
- Department of Neuropathology, The Ottawa Hospital, Ottawa, Ontario, Canada
| | - Hugues Duffau
- Department of Neurosurgery, Hôpital Gui de Chauliac, Montpellier University Medical Center, Montpellier, France.,Brain Plasticity, Stem Cells, and Glial Tumors Team, National Institute for Health and Medical Research, Montpellier, France
| | - Jin-Song Wu
- Glioma Surgery Division, Neurologic Surgery Department, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China
| | - Georg Northoff
- Mind, Brain Imaging, and Neuroethics, Institute of Mental Health Research, University of Ottawa, Ottawa, Ontario, Canada
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5-Aminolevulinic acid for recurrent malignant gliomas: A systematic review. Clin Neurol Neurosurg 2020; 195:105913. [DOI: 10.1016/j.clineuro.2020.105913] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2020] [Revised: 03/28/2020] [Accepted: 05/10/2020] [Indexed: 11/24/2022]
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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.
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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
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Napier TS, Udayakumar N, Jani AH, Hartman YE, Houson HA, Moore L, Amm HM, van den Berg NS, Sorace AG, Warram JM. Comparison of Panitumumab-IRDye800CW and 5-Aminolevulinic Acid to Provide Optical Contrast in a Model of Glioblastoma Multiforme. Mol Cancer Ther 2020; 19:1922-1929. [PMID: 32606015 DOI: 10.1158/1535-7163.mct-19-0819] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2019] [Revised: 01/16/2020] [Accepted: 06/15/2020] [Indexed: 01/02/2023]
Abstract
Maximal safe resection of malignant tissue is associated with improved progression-free survival and better response to radiation and chemotherapy for patients with glioblastoma (GBM). 5-Aminolevulinic acid (5-ALA) is the current FDA-approved standard for intraoperative brain tumor visualization. Unfortunately, autofluorescence in diffuse areas and high fluorescence in dense tissues significantly limit discrimination at tumor margins. This study is the first to compare 5-ALA to an investigational new drug, panitumumab-IRDye800CW, in the same animal model. A patient-derived GBM xenograft model was established in 16 nude mice, which later received injections of 5-ALA, panitumumab-IRDye800CW, IRDye800CW, 5-ALA and IRDye800CW, or 5-ALA and panitumumab-IRDye800CW. Brains were prepared for multi-instrument fluorescence imaging, IHC, and quantitative analysis of tumor-to-background ratio (TBR) and tumor margin accuracy. Statistical analysis was compared with Wilcoxon rank-sum or paired t test. Panitumumab-IRDye800CW had a 30% higher comprehensive TBR compared with 5-ALA (P = 0.0079). SDs for core and margin regions of interest in 5-ALA-treated tissues were significantly higher than those found in panitumumab-IRDye800CW-treated tissues (P = 0.0240 and P = 0.0284, respectively). Panitumumab-IRDye800CW specificities for tumor core and margin were more than 10% higher than those of 5-ALA. Higher AUC for panitumumab-IRDye800CW indicated strong capability to discriminate between normal and malignant brain tissue when compared with 5-ALA. This work demonstrates that panitumumab-IRDye800CW shows potential as a targeting agent for fluorescence intraoperative detection of GBM. Improved margin definition and surgical resection using panitumumab-IRDye800 has the potential to improve surgical outcomes and survival in patients with GBM compared with 5-ALA.
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Affiliation(s)
- Tiara S Napier
- Graduate Biomedical Sciences, University of Alabama at Birmingham, Birmingham, Alabama
| | - Neha Udayakumar
- School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | - Aditi H Jani
- Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | - Yolanda E Hartman
- Department of Otolaryngology, University of Alabama at Birmingham, Birmingham, Alabama
| | - Hailey A Houson
- Department of Otolaryngology, University of Alabama at Birmingham, Birmingham, Alabama
| | - Lindsay Moore
- Department of Otolaryngology, University of Alabama at Birmingham, Birmingham, Alabama
| | - Hope M Amm
- Department of Oral and Maxillofacial Surgery, University of Alabama at Birmingham, Birmingham, Alabama
| | - Nynke S van den Berg
- Department of Otolaryngology, Stanford University Medical School, Stanford, California
| | - Anna G Sorace
- Department of Radiology, University of Alabama at Birmingham, Birmingham, Alabama.,O'Neal Comprehensive Cancer Center, University of Alabama at Birmingham, Birmingham, Alabama
| | - Jason M Warram
- Department of Otolaryngology, University of Alabama at Birmingham, Birmingham, Alabama. .,O'Neal Comprehensive Cancer Center, University of Alabama at Birmingham, Birmingham, Alabama
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Canada, Neurosurgery, and 5-Aminolevulinic Acid (5-ALA): The Long and Winding Road. Can J Neurol Sci 2020; 47:734-735. [PMID: 32475358 DOI: 10.1017/cjn.2020.107] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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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.
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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
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5-Aminolevulinic Acid Hydrochloride (5-ALA)-Guided Surgical Resection of High-Grade Gliomas: A Health Technology Assessment. ONTARIO HEALTH TECHNOLOGY ASSESSMENT SERIES 2020; 20:1-92. [PMID: 32194883 PMCID: PMC7077938] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
BACKGROUND High-grade gliomas are a type of malignant brain tumour. Optimal management often includes maximal surgical resection. 5-aminolevulinic acid hydrochloride (5-ALA) is an imaging agent that makes a high-grade glioma fluoresce under blue light, which can help guide the surgeon when removing the tumour. We conducted a health technology assessment of 5-ALA-guided surgical resection of high-grade gliomas, which included an evaluation of effectiveness, safety, the budget impact of publicly funding 5-ALA, and patient preferences and values. METHODS We performed a systematic literature search of the clinical evidence to retrieve systematic reviews, and selected and reported results from one review that was recent, of high quality, and relevant to our research question. We complemented the identified systematic review with a literature search to identify randomized controlled trials published after the review. We reported the risk of bias of each included study and the quality of the body of evidence according to the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) Working Group criteria. We also performed a systematic economic literature search to identify economic studies that compared 5-ALA-guided surgical resection of high-grade gliomas with standard surgical care or other intraoperative imaging modalities. We did not conduct a primary economic evaluation due to lack of high-quality published clinical evidence evaluating 5-ALA-guided surgical resection. From the perspective of the Ontario Ministry of Health, we analyzed the 5-year budget impact of publicly funding 5-ALA-guided surgical resection for adults with newly diagnosed, primary, high-grade gliomas for which resection is considered feasible. To contextualize the potential value of 5-ALA, we spoke with someone who had experience with high-grade glioma, 5-ALA-guided resection, and standard surgical treatment. RESULTS We included one systematic review reporting on a single randomized controlled trial in the clinical evidence review. 5-ALA increased the proportion of patients achieving complete tumour resection compared with standard care (relative risk of incomplete resection 0.55, 95% confidence interval 0.42-0.71; GRADE: Low). Evidence was uncertain for an effect on overall survival with 5-ALA (hazard ratio for death 0.82, 95% confidence interval 0.62-1.07; GRADE: Low), but there may be an improvement in 6-month progression-free survival (GRADE: Very low). Adverse events between groups was insufficiently reported, but appeared similar between groups for overall and neurological adverse events, with an observed increase in neurological deficits 48 hours after surgery with 5-ALA (GRADE: Very low). The economic literature search identified five studies that met our inclusion criteria because they evaluated the cost-effectiveness of 5-ALA-guided surgical resection as compared with surgery with a standard operating microscope under white light ("white-light microscopy"). Most of these studies found 5-ALA-guided surgical resection was cost-effective compared to white-light microscopy for high-grade gliomas. However, all studies derived clinical model inputs of the comparative safety and effectiveness parameters of 5-ALA from limited and low-quality evidence. Public funding of 5-ALA-guided surgical resection in Ontario over the next 5 years would result in a budget impact of about $930,000 in year 1 to about $1,765,000 in year 5, yielding a total budget impact of about $7,500,000 over this period. The one participant we interviewed had experience with high-grade glioma, standard surgical treatment, and 5-ALA-guided resection. The participant felt that 5-ALA-guided resection resulted in accurate tumour removal and also found it reassuring that 5-ALA could help the surgeon better visualize the tumour. CONCLUSIONS 5-ALA-guided surgical resection appears to improve the extent of resection of high-grade gliomas compared with surgery using standard white-light microscopy (GRADE: Low). The evidence suggests 5-ALA-guided resection may improve overall survival; however, we cannot exclude the possibility of no effect (Grade: Low). 5-ALA may improve 6-month progression-free survival, although the results are highly uncertain (GRADE: Very low). There is an uncertain impact on overall or neurological adverse events (GRADE: Very low). We did not identify any economic studies conducted from the perspective of the Ontario or Canadian public health care payer. Of the studies that met our inclusion criteria, most found 5-ALA-guided surgical resection was cost-effective compared to white-light microscopy for high-grade gliomas. However, clinical model inputs for the comparative effectiveness and safety of 5-ALA were based on limited and low-quality evidence. We estimate that publicly funding 5-ALA-guided surgical resection in Ontario over the next 5 years would result in a total 5-year budget impact of about $7,500,000. For people diagnosed with high-grade gliomas, 5-ALA is seen positively as a useful imaging tool for brain tumour resection.
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50
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Kenan S, Liang H, Goodman HJ, Jacobs AJ, Chan A, Grande DA, Levin AS. 5-Aminolevulinic acid tumor paint and photodynamic therapy for myxofibrosarcoma: an in vitro study. J Orthop Surg Res 2020; 15:94. [PMID: 32138774 PMCID: PMC7059315 DOI: 10.1186/s13018-020-01606-9] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2019] [Accepted: 02/17/2020] [Indexed: 02/06/2023] Open
Abstract
Background 5-Aminolevulinic acid (5-ALA), a fluorescent contrast agent, has been used for tumor paint and photodynamic therapy (PDT) for various tumors, but its use with soft tissue sarcomas is not well documented. Myxofibrosarcoma, a subtype of soft tissue sarcoma with a high local recurrence rate, may benefit from similar types of treatment. The purpose of this study was to analyze the effects of 5-ALA tumor paint and PDT on a myxofibrosarcoma cell line. Methods Tumor paint was assessed by exposing micromass pellets of human adipose-derived stromal (ADS) cells or myxofibrosarcoma (MUG-Myx1) cells to 5-ALA. Cell pellets were then visualized using a microscope at established excitation and emission wavelengths. Corrected total cell fluorescence was calculated per accepted protocols. Photodynamic therapy was similarly assessed by exposing ADS and MUG-Myx1 cells to 5-ALA, with subsequent analysis via flow cytometry and real-time confocal microscopy. Results The use of 5-ALA tumor paint led to a selective fluorescence in MUG-Myx1 cells. Findings were confirmed by flow cytometry. Interestingly, flow cytometry results showed progressive selective cell death with increasing 5-ALA exposure as a result of the PDT effect. PDT was further confirmed using confocal microscopy, which revealed progressive cellular bubble formation consistent with advancing stages of cell death—a finding that was not seen in control ADS cells. Conclusions 5-ALA tumor paint and PDT were successfully used on a human myxofibrosarcoma cell line (MUG-Myx1). Results from this study showed both selective fluorescent tagging and selective cytotoxicity of 5-ALA toward malignant myxofibrosarcoma cells, while sparing benign adipose control cells. This finding was further confirmed in a dramatic time-lapse video, visually confirming active, targeted cell death. 5-ALA’s two-pronged application of selective tumor identification and cytotoxicity may transform surgical and medical approaches for treating soft tissue sarcomas.
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Affiliation(s)
- Shachar Kenan
- Department of Orthopaedic Surgery, North Shore-Long Island Jewish Hospital, Northwell Health System, 270-05 76th Avenue, New Hyde Park, NY, 11040, USA
| | - Haixiang Liang
- Orthopaedic Research Laboratory, The Feinstein Institute for Medical Research, 350 Community Drive, Manhasset, NY, 11030, USA
| | - Howard J Goodman
- Department of Orthopaedic Surgery, North Shore-Long Island Jewish Hospital, Northwell Health System, 270-05 76th Avenue, New Hyde Park, NY, 11040, USA
| | - Andrew J Jacobs
- Hofstra Northwell School of Medicine, 500 Hofstra University, Hempstead, NY, 11549, USA
| | - Amanda Chan
- Microscopy Facility, The Feinstein Institute for Medical Research, 350 Community Drive, Manhasset, NY, 11030, USA
| | - Daniel A Grande
- Orthopaedic Research Laboratory, The Feinstein Institute for Medical Research, 350 Community Drive, Manhasset, NY, 11030, USA
| | - Adam S Levin
- Department of Orthopaedic Surgery and Oncology, The Johns Hopkins University School of Medicine, 601 North Caroline Street, Baltimore, MD, 21287, USA.
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