The impact of fluorescein-guided technique in the surgical removal of CNS tumors in a pediatric population: results from a multicentric observational study

Role of sodium fluorescein in pediatric low-grade glioma surgery: an update

PURPOSE

Complete surgical resection is still the mainstay in the treatment of central nervous system low-grade tumors, eventually resulting curative. The complete surgical removal of these lesions, however, may be difficult in some cases because of their infiltrative nature. Intraoperative adjuncts may be a game changer. Sodium fluorescein (SF) is among the ideal candidates as intraoperative tools to favor the actual recognition of the tumor extension, since it accumulates in areas of altered blood-brain barrier, a typical characteristic of pediatric gliomas, and has a low rate of adverse events. This work proposes an update of previous works about the evaluation of the feasibility and usefulness of a systematic use of SF in a low-grade lesion group of pediatric patients.

METHODS

Pediatric patients operated on for a resection or a biopsy of a low-grade glial or glioneuronal lesion (WHO grade I and II) at our Institution between September 2021 and December 2023, with the intraoperative use of sodium fluorescein (SF), were enrolled in the study. We collected pre-operative and postoperative clinical and radiological data, intraoperative findings, and post-operative pathological diagnoses.

RESULTS

No adverse events were registered related to the intraoperative use of SF. SF appeared useful for the localization of boundaries of tumors, especially when characterized by a high degree of infiltration or by a deep-seated location, and for the checking of possible tumor remnants at the end of surgery. A good tumor-to-healthy tissue contrast was registered when tumor visualization was in a range between 1 to 2 h and 30 min after SF injection. Possible "false positives" due to intraoperative vascular wall injury and clearance of SF from both tumor and healthy tissue were observed in some cases and still remain open issues.

CONCLUSIONS

SF is a feasible and safe intraoperative adjunct tool in the surgical removal of pediatric low-grade tumors. SF may show its usefulness especially in selected cases, such as deep-seated lesions and infiltrating tumors. Its safety profile, user-friendly management, and potential utility in both tumor resections and neuronavigated biopsies favor its wider use in the surgical treatment of pediatric low-grade tumors.

The usefulness of intraoperative sodium fluorescein in the surgical treatment of relapsed high-grade brain tumors in pediatric patients

PURPOSE

We report the usefulness of intraoperative sodium fluorescein (SF) in the surgical treatment of relapsed high-grade brain tumors in pediatric neurosurgery.

METHODS

We describe our protocol for intraoperative SF and three cases of patients between 5 and 11 years diagnosed and surgically treated for relapsed high-grade brain tumors using SF.

RESULTS

The 560-nm microscope filter enables the use of low doses of this fluorochrome. A dose of 3 mg/kg of patient weight of 10% SF, administered intravenously, is safe and effective in children. The effect of SF was immediate, providing a clear margin between the tumor and healthy tissue, which enabled good tumor resection. We observed no adverse effects in the postoperative period, and the patients evolved satisfactorily.

CONCLUSIONS

To the best of our knowledge, we describe for the first time the use of fluorescein in reoperations of relapsed high-grade brain tumors in childhood with promising results. Using SF in children is a safe, affordable, and effective technique that offers an excellent intraoperative image, being a feasible option to improve oncological resection. This study is one of the few that uses SF in pediatric neurosurgery, where it could be very beneficial.

Assessing the role of sodium fluorescein in peripheral nerve sheath tumors and mimicking lesions surgery: An update after 142 cases

Objective

Peripheral nerve sheath tumors (PNST) include mainly schwannomas and neurofibromas. Surgical resection represents the mainstay of treatment but due to their pathogenesis, distinguishing between intact functional nerve and the fibers from whence the PNST arose may not always be easy to perform, constituting the most relevant risk factor in determining a worsening in neurological condition. The introduction of intraoperative tools to better visualize these tumors could help achieve a gross-total resection. In this study, we analyzed the effect of sodium fluorescein (SF) on the visualization and resection of a large cohort of PNST.

Methods

Between September 2018 and December 2021, 142 consecutive patients harboring a suspected PNST underwent fluorescein-guided surgery at the Department of Neurosurgery of the Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy. All patients presented with a different degree of contrast enhancement at preoperative MRI. SF was intravenously injected after intubation at 1 mg/kg. Intraoperative fluorescein characteristics and postoperative neurological and radiological outcomes were collected, analyzed, and retrospectively compared with a historical series.

Results

142 patients were included (42 syndromic and 100 sporadic); schwannoma was the predominant histology, followed by neurofibroma (17 neurofibroma e 12 plexiform neurofibroma) and MPNST. Bright fluorescence was present in all cases of schwannomas and neurofibromas, although with a less homogeneous pattern, whereas it was significantly less evident for malignant PNST; perineurioma and hybrid nerve sheath tumors were characterized by a faint fluorescence enhancement. The surgical resection rate in the general population and even among the subgroups was about 66.7%; from the comparative analysis, we found a consistently higher rate of complete tumor removal in plexiform neurofibromas, 66% in the "fluorescent" group vs 44% in the "historical" group (p-value < 0.05). The rate of complications and mean surgical time were superimposable among the two populations.

Conclusions

SF is a valuable method for safe fluorescence-guided PNST and mimicking lesions resection. Our data showed a positive effect of fluorescein-guided surgery in increasing the rate of surgical resection of plexiform neurofibromas, suggesting a possible role in improving the functional and oncological outcome of these lesions.

The use of the sodium fluorescein and YELLOW 560 nm filter for the resection of pediatric posterior fossa lesions

PURPOSE

This study aimed to verify the feasibility, safety, and benefit of using fluorescein sodium (FL) and a YELLOW 560 nm filter in posterior fossa tumors in children.

METHODS

All cases of pediatric posterior fossa tumors that have undergone surgery using fluorescein (2018-2022) have been included and were examined retrospectively. In those cases where resection of the tumor was planned, a blinded neuroradiologist distinguished gross total resection and subtotal resection according to the postoperative MRI findings. The surgical report and medical files were reviewed regarding the intraoperative staining grade and adverse events. The grade of fluorescent staining of the targeted lesion was assessed as described in the surgical reports. The screening was conducted for any reference to the degree of fluorescent staining: "intense," "medium," "slight," and "no staining."

RESULTS

19 cases have been included. In 14 cases, a complete resection was initially intended. In 11 of these cases, a gross total resection could be achieved (78.6%). Staining was described as intense in most cases (58.8%). Except for yellow-colored urine, no side effects obviously related to FL were found throughout the observation period.

CONCLUSION

In combination with a specific filter, FL is a reliable, safe, and feasible tool in posterior fossa surgery in children.

The role of sodium fluorescein in pediatric supratentorial intra-axial tumor resection: new insights from a monocentric series of 33 consecutive patients

INTRODUCTION

Surgical resection represents the mainstay of treatment, in pediatric central nervous system (CNS) tumors, and aggressive resection correlates with prognosis for several histotypes. Sodium fluorescein (SF), a green, water-soluble dye, is used as neurosurgical fluorescent tracer thanks to its property to accumulate in cerebral regions of blood-brain barrier disruption, acting as a valid tool to improve the extent of resection in tumors enhancing at preoperative MRI. Brain neoplasms represent a heterogeneous group of tumors in the pediatric age, constituting the most common solid cancers; they typically show a varying degree of contrast enhancement on MRI.

MATERIALS AND METHODS

In March 2016, the authors started a prospective, observational trial to evaluate intraoperative fluorescence's characteristics of CNS tumors, the percentage of extent of resection, thanks to fluorescein aid, and side effects related to fluorescein administration. This report is based on a retrospective analysis of a group of 33 consecutive pediatric patients harboring a supratentorial lesion.

RESULTS

In 17 of 33 (51.5%) procedures, fluorescence was reported as intense; in 14 of 33 (42.4%), moderate; and in 2 of 33 (6.1%), slight. Intraoperative fluorescence corresponds to preoperative-MRI-documented contrast enhancement. In 28 of 33 (84.8%) surgical procedures, SF was considered useful; in 2 of 33 (6.1%), partial useful; and in 3 of 33 (9.1%), not essential because the tumor was already recognizable. No adverse effect to SF administration was registered.

CONCLUSION

Fluorescein-guided surgery with a dedicated filter on the microscope is a safe and effective technique to improve visualization and resection of different pediatric brain tumors.

Sodium fluorescein in pediatric neurosurgery: a systematic review with technical considerations and future perspectives

BACKGROUND

Sodium fluorescein (SF) is routinely used in several centers as a valid intraoperative adjunct in adult oncological neurosurgery. Its use in pediatric neurosurgery is increasing, although its role is not yet well-defined in children. We reviewed the current literature in order to evaluate the use of SF in children with CNS and PNS lesions.

METHODS

For this systematic review, we searched PubMed, Scopus, and Embase databases, and forward and backward citations for studies published between database inception and July 31st, 2022. We included any article type or congress abstract adding at least a new case, without restrictions of language or publication status, concerning the use of SF in neurosurgical procedures in patients under 18 years of age. We excluded studies concerning purely vascular cases and cerebrospinal fluid leaks.

RESULTS

Of 4094 records identified, 19 articles were eligible and included for further analysis. As per July 31st, 2022, at least 119 patients aged from 11 months to 17.9 years underwent surgery with SF. No serious adverse events were reported. A large variety of tumor types was operated, in most cases resected under the specific YELLOW 560 nm filter after a low-dose SF injection (2-5 mg/kg) at the end of anesthesia induction. SF was reported particularly useful in gangliogliomas and pilocytic astrocytomas.

DISCUSSION/CONCLUSION

Given its easy-to-use profile, low cost, and safety, SF seems to be a feasible and valid adjunct in the pediatric population when aiming at individuating a biopsy target or maximizing extent of resection, particularly in some tumor types. Further studies are required to strengthen the evidence on its impact on outcomes.

Fluorescein-guided resection for pediatric low-grade gliomas: institutional experience on two cases and a narrative literature review

PURPOSE

Low-grade gliomas compose 30% of pediatric central nervous system tumors and outcomes of disease-free progression, and survival is directly correlated to the extent of resection. The use of sodium fluorescein (Na-Fl) is an intraoperative method in the localization of tumor cells in adult patients to optimize resection. Our purpose is to describe the use of Na-Fl in pediatric low-grade gliomas and its outcomes.

METHODS

Patients under 18 years of age with low-grade gliomas at the author's institution underwent resection with the use of Na-Fl, with review of preoperative imaging findings, intraoperative results, and follow-up. Then, a comprehensive, narrative literature review of the use of Na-Fl in pediatric low-grade glioma was performed.

RESULTS

Our single-institution use of Na-Fl in pediatric patients with suspected low-grade glioma demonstrated excellent results of intraoperative enhancement of tumor cells as well as gross total resection. The literature demonstrated 84% Na-Fl staining and 59.2% of gross total resection in pediatric low-grade gliomas with few small case studies, a range of reported findings, and few side effects.

CONCLUSION

Na-Fl has a promising use in low-grade glioma resection in the pediatric patient population. Further research is warranted, such as randomized controlled studies, to assess Na-Fl as a potential tool in improving resection and long-term favorable outcomes.

Fluorescein sodium in the surgical treatment of pleomorphic xanthoastrocytomas: Results from a retrospective study

OBJECTIVE

Pleomorphic xanthoastrocytoma (PXA) is a rare brain tumor, most commonly affecting children and young adults. Surgical resection represents the mainstay of treatment, and extent of resection is associated with improved survival. In this study, we analyzed the role of sodium fluorescein (SF) in improving intraoperative visualization easing resection.

METHODS

Surgical database of FLUOCERTUM study (Besta Institute, Milan, Italy) was retrospectively reviewed to find pleomorphic xanthoastrocytomas and anaplastic xanthoastrocytomas, according to WHO-2016/2021 classification, surgically removed by a fluorescein-guided technique from March 2016 to February 2022. SF was intravenously injected (5mg/kg) immediately after induction of general anesthesia. Tumors were removed using a microsurgical technique with the YELLOW 560 filter (Carl Zeiss Meditec, Oberkochen, Germany).

RESULTS

Twelve patients (7 males and 5 females; 3 pediatric patients, mean age 10 years, range 5 to 13 years and 9 adult patients, mean age 50.6 years, range 35 to 63 years) underwent fluorescein-guided surgery. No side effects related to SF occurred. In all tumors, contrast enhancement on preoperative MRI correlated with intense, heterogeneous yellow fluorescence with bright fluorescent cystic fluid. Fluorescein was considered helpful in distinguishing tumors from viable tissue in all cases. Gross total resection was achieved in 8 cases (66.7%); in 4 cases, otherwise, the resection was subtotal with fluorescent residual spots to avoid neurological worsening (33.3%).

CONCLUSIONS

The use of SF is a valuable method for safe fluorescence-guided tumor resection. Our data documented a positive effect of fluorescein-guided surgery on intraoperative visualization, suggesting a probable role in improving the extent of resection during yellow surgery of PXA.

Fluorescein-guided surgery for the resection of pilocytic astrocytomas: A multicentric retrospective study

Objective

Pilocytic astrocytomas (PAs) are relatively benign tumors, usually enhancing on post-contrast MRI and often characterized by a mural nodule within a cystic component. Surgical resection represents the mainstay of treatment, and extent of resection (EOR) is associated with improved survival. In this study, we analyzed the effect of sodium fluorescein (SF) on the visualization and resection of these circumscribed astrocytic gliomas.

Methods

Surgical databases at two neurosurgical departments (Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy and Department of Neurosurgery, University Medical Center Regensburg, Regensburg, Germany) were retrospectively reviewed to identify the cohort of patients with pilocytic astrocytoma who had undergone fluorescein-guided tumor resection at any of the centers between March 2016 and February 2022. SF was intravenously injected (5 mg/kg) immediately after the induction of general anesthesia. Tumors were removed using a microsurgical technique with the YELLOW 560 filter (Carl Zeiss Meditec, Oberkochen, Germany).

Results

Forty-four patients (25 males and 19 females; 26 pediatric patients, mean age of 9.77 years, range 2 to 17 years; and 18 adult patients, mean age of 34.39 years, range 18 to 58 years) underwent fluorescein-guided surgery. No side effects related to SF occurred. In all tumors, contrast enhancement on preoperative MRI was correlated with intense, heterogeneous yellow fluorescence with bright fluorescent cystic fluid. Fluorescein was considered helpful in distinguishing tumors from viable tissue in all cases except three patients due to faint fluorescein enhancement. Biopsy was intended in two operations, and partial resection was intended in three operations. Gross total resection was achieved in 24 cases out of 39 patients scheduled for tumor removal (61.54%), in five cases a minimal residual volume was highlighted by postoperative MRI despite the intraoperative subjective evaluation of complete tumor removal (12.82%); in the other 10 cases, the resection was subtotal with fluorescent residual spots to avoid neurological worsening (25.64%).

Conclusions

The use of SF is a valuable method for safe fluorescence-guided tumor resection. Our data showed a positive effect of fluorescein-guided surgery on intraoperative visualization during resection of Pas, suggesting a possible role in improving the extent of resection of these lesions.

Fluorescence-Guided Surgery: A Review on Timing and Use in Brain Tumor Surgery

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.

Intraoperative Sodium-Fluorescence Imaging in Peripheral Nerve Sheath Tumors (PNST)-A New Additional Promising Diagnostic Tool

Background: Through the development and implementation of specific fluorophore filters to microscopes in 2012, sodium fluorescein (SF) is currently experiencing a remarkable renaissance in neurosurgery. The present study examines its intraoperative application during surgical removal of peripheral nerve sheath tumors (PNST) and metastases. Methods: This single-center study includes 10 cases of benign and malignant tumors as well as metastases of peripheral nerves (in total 11 PNST). Their surgical resections were all performed under microscope-based fluorescence with SF, which was administered intravenously (0.5-1.0 mg/kg body weight) during anesthesia induction. Microsurgical tumor removals were filmed and the collected data were retrospectively analyzed via ImageJ. Results: Microsurgical tumor preparation was possible under the usage of fluorophore filter. In seven histological confirmed schwannoma (n = 6 patients) tissue differentiation between tumor mass and not involved fascicles was statistically significant for the colors green and red. Schwannoma maximum mean for green reached 254.7 pixel and 179.4 pixel for red, whereas passing healthy fascicles revealed a maximum mean for green 94.91 and for red 120.76 pixel. One case of neurofibroma achieved lower amount of pixel. Similar to schwannoma, the two MPNST cases showed a strong homogeneous fluorescence (max. mean green 215 pixel and red 124.51) involving the whole nerve segment. Subcutaneous tumor remnants were visualized and therefore resected. Via fascicular nerve biopsy a B-cell lymphoma of the tibial nerve could be detected. SF led to variable stain intensities in single fascicles. The resected fascicle revealed a max mean green of 100.54 pixel, whereas surrounding fascicles came up with max. mean green of 63.0 pixel. Conclusions: Intraoperative SF visualization for PNST is feasible and of low risk. During resection of benign PNST, enhanced tissue differentiation between affected and not affected nerve segments is very useful. Tumor remnants can be detected safely and effectively. Its application during resection of malignant PNST is limited. Due to the infiltrative nature of those tumors, intraneural tissue differentiation is not possible. "Fluorescence-guided" biopsy can be regarded as an additional advantage in PNST surgery. Due to the encouraging experience in our institution SF was established as standard visualization tool in PNST surgery.