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Hsieh AL, Bi WL, Ramesh V, Brastianos PK, Plotkin SR. Evolving concepts in meningioma management in the era of genomics. Cancer 2024; 130:2586-2600. [PMID: 38753473 PMCID: PMC11260245 DOI: 10.1002/cncr.35279] [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: 04/08/2023] [Revised: 01/31/2024] [Accepted: 02/19/2024] [Indexed: 05/18/2024]
Abstract
Meningioma is the most common type of primary brain tumor. Surgical resection followed by surveillance is the first-line treatment for the majority of symptomatic meningiomas; however, recent advances in molecular sequencing, DNA methylation, proteomics, and single-cell sequencing provide insights into further characterizing this heterogeneous group of tumors with a wide range of prognoses. A subset of these tumors are highly aggressive and cause severe morbidity and mortality. Therefore, identifying those individuals with a poor prognosis and intervening are critical. This review aims to help readers interpret the molecular profiling of meningiomas to identify patients with worse prognoses and guide the management and strategy for surveillance.
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Affiliation(s)
- Annie L. Hsieh
- Department of Neurology and Cancer Center, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Wenya Linda Bi
- Department of Neurosurgery, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA, USA
| | - Vijaya Ramesh
- Department of Neurology and Center for Genomic Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Priscilla K Brastianos
- Department of Neurology and Cancer Center, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
- Central Nervous System Metastasis Program, Massachusetts General Hospital, Boston, MA, United States
- Division of Hematology/Oncology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Scott R. Plotkin
- Department of Neurology and Cancer Center, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
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2
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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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3
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Takeda J, Nonaka M, Li Y, Isozaki H, Kamei T, Hashiba T, Yoshimura K, Asai A. 5-Aminolevulinic acid fluorescence-guided endoscopic surgery for deep-seated intraparenchymal tumors. Br J Neurosurg 2023:1-5. [PMID: 37997374 DOI: 10.1080/02688697.2023.2283129] [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: 08/09/2021] [Accepted: 11/08/2023] [Indexed: 11/25/2023]
Abstract
AIM The usefulness of 5-aminolevulinic acid (5-ALA) fluorescence-assisted surgery for maximum resection of malignant gliomas has been established. However, its usefulness when combined with endoscopic surgery for deep-seated tumors has not been well established. In this study, whether 5-ALA photodynamic diagnosis (PDD) is feasible and useful for endoscopic surgery was investigated. METHODS A specially designed endoscope for PDD that delivers white light or blue light (375-440 nm) as excitation light was used. The fluorescence emitted by the tumor was evaluated in the cavity during resection or at the tip of the sheath during biopsy. The intensity of fluorescence was classified into three categories: strong, vague, and negative. RESULTS A total of 30 intraparenchymal tumors were observed with a neuroendoscope and 5-ALA PDD; 16 patients underwent resection, and 14 underwent biopsy. Overall, 67% (20/30) of tumors showed positive fluorescence of protoporphyrin IX. High-grade gliomas (HGGs) including glioblastoma (GBM) and anaplastic astrocytoma (AA) showed strong fluorescence in 47% (7/15), vague fluorescence in 33% (5/15), and negative fluorescence in 20% (3/15) of cases. Low-grade gliomas (LGGs) showed vague fluorescence in 33% (1/3) and negative fluorescence in 67% (2/3). Diffuse large B-cell lymphoma (DLBCL) showed vague fluorescence in 38% (3/8) and negative fluorescence in 63% (5/8). Metastatic tumors showed strong fluorescence in 25% (1/4) and vague fluorescence in 75% (3/4). In the comparison of fluorescence evaluation, a significant difference was observed only in the comparison between HGGs and DLBCL (p = 0.049). CONCLUSION These results suggest that 5-ALA PDD-assisted endoscopic surgery is feasible and useful for deep-seated intraparenchymal tumors.
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Affiliation(s)
- Junichi Takeda
- Department of Neurosurgery, Kansai Medical University Hospital, Osaka, Japan
| | - Masahiro Nonaka
- Department of Neurosurgery, Kansai Medical University Hospital, Osaka, Japan
| | - Yi Li
- Department of Neurosurgery, Kansai Medical University Hospital, Osaka, Japan
| | - Haruna Isozaki
- Department of Neurosurgery, Kansai Medical University Hospital, Osaka, Japan
| | - Takamasa Kamei
- Department of Neurosurgery, Kansai Medical University Hospital, Osaka, Japan
| | - Tetsuo Hashiba
- Department of Neurosurgery, Kansai Medical University Hospital, Osaka, Japan
| | - Kunikazu Yoshimura
- Department of Neurosurgery, Kansai Medical University Hospital, Osaka, Japan
| | - Akio Asai
- Department of Neurosurgery, Kansai Medical University Hospital, Osaka, Japan
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4
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García Moreno R, Ippolito Bastidas H, Fernández Portales I, Rubio Fernández A, Hidalgo Llorca M, Cabezudo Artero JM. 5-aminolevulinic acid fluorescence guided surgery for resection of cystic meningioma with bone invasion. Br J Neurosurg 2023; 37:1223-1227. [PMID: 33095079 DOI: 10.1080/02688697.2020.1837729] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2019] [Accepted: 10/13/2020] [Indexed: 10/23/2022]
Abstract
Meningiomas have a 5 year recurrence rate of 8%. Histological grade and extent of resection are the two main prognostic factors. Cystic meningiomas represent between 2 and 4% of meningiomas, and the complete resection rate in these cases is 62.7%. 5-ALA has been shown to be useful in detecting tumour remnants that could go unnoticed by the conventional microsurgical technique, thereby achieving more complete resections. We present the case of a 66-year-old patient with a frontal convexity meningioma, presenting with a cystic component and bone invasion, who was treated using 5-ALA fluorescence-guided surgery. Fluorescence emission from the tumour tissue allowed the areas of bone invasion and the cystic wall to be identified, achieving complete resection.
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Affiliation(s)
- Rafael García Moreno
- Department of Neurosurgery, University Hospital Complex of Badajoz, Badajoz, Spain
| | | | | | | | - María Hidalgo Llorca
- Department of Neurosurgery, University Hospital Complex of Badajoz, Badajoz, Spain
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5
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Peciu-Florianu I, Jaillard A, Tuleasca C, Reyns N. Benefits of combined use of 68-Ga Dotatoc and 5-ALA fluorescence for recurrent atypical skull-base meningioma after previous microsurgery and Gamma Knife radiosurgery: a case report. J Med Case Rep 2023; 17:300. [PMID: 37452350 PMCID: PMC10349456 DOI: 10.1186/s13256-023-04023-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2022] [Accepted: 06/06/2023] [Indexed: 07/18/2023] Open
Abstract
BACKGROUND Studies of novel microsurgical adjuncts, such as 5-aminolevulinic acid (5-ALA) fluorescence have shown various fluorescence patterns within meningiomas, opening new avenues for complete microsurgical resection. Here, we present a recurrent, radiation-induced meningioma, previously operated on two occasions (initial gross total resection and subtotal 12 years later) and also irradiated by Gamma Knife radiosurgery (GKR, 6 years after the first surgery). We thought to assess the usefulness of 68-Ga Dotatoc in surgical target planning and of 5-ALA as an adjunct for maximal microsurgical excision. CASE REPORT We report on a 43 years-old Caucasian male diagnosed with atypical, radiation induced WHO II meningioma, with left basal temporal bone implantation. Hodgkin lymphoma treated with cranial and mediastinal radiation during infancy marked his personal history. He underwent a first gross total microsurgical resection, followed 6 and 12 years later by Gamma Knife radiosurgery (GKR) and second subtotal microsurgical resection, respectively. Magnetic resonance imaging (MRI) displayed new recurrence 13 years after initial diagnosis. He was clinically asymptomatic but routine Magnetic resonance imaging showed constant progression. There was strong 68-Ga Dotatoc uptake. We used 5-ALA guided microsurgical resection. Intraoperative views confirmed strong fluorescence, in concordance with both preoperative Magnetic resonance imaging enhancement and 68-Ga Dotatoc. The tumor was completely removed, with meningeal and bone resection. CONCLUSION The authors conclude that fluorescence-guided resection using 5-ALA is useful for recurrent atypical, radiation-induced meningioma even despite previous irradiation and multiple recurrences.
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Affiliation(s)
| | - Alice Jaillard
- Nuclear Medicine and Functional Imaging, CHU Lille, Roger Salengro Hospital, Lille, France
| | - Constantin Tuleasca
- Neurosurgery Service, CHU Lille, Roger Salengro Hospital, Lille, France.
- Department of Clinical Neurosciences, Neurosurgery Service and Gamma Knife Center, Lausanne University Hospital (CHUV), Rue du Bugnon 44-46, BH-08, CH-1011, Lausanne, Switzerland.
- Faculty of Biology and Medicine (FBM), University of Lausanne (Unil), Lausanne, Switzerland.
- Signal Processing Laboratory (LTS 5), Ecole Polytechnique Fédérale de Lausanne (EPFL), Lausanne, Switzerland.
| | - Nicolas Reyns
- Neurosurgery Service, CHU Lille, Roger Salengro Hospital, Lille, France
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Klint E, Richter J, Wårdell K. Combined Use of Frameless Neuronavigation and In Situ Optical Guidance in Brain Tumor Needle Biopsies. Brain Sci 2023; 13:brainsci13050809. [PMID: 37239281 DOI: 10.3390/brainsci13050809] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2023] [Revised: 05/10/2023] [Accepted: 05/13/2023] [Indexed: 05/28/2023] Open
Abstract
Brain tumor needle biopsies are performed to retrieve tissue samples for neuropathological analysis. Although preoperative images guide the procedure, there are risks of hemorrhage and sampling of non-tumor tissue. This study aimed to develop and evaluate a method for frameless one-insertion needle biopsies with in situ optical guidance and present a processing pipeline for combined postoperative analysis of optical, MRI, and neuropathological data. An optical system for quantified feedback on tissue microcirculation, gray-whiteness, and the presence of a tumor (protoporphyrin IX (PpIX) accumulation) with a one-insertion optical probe was integrated into a needle biopsy kit that was used for frameless neuronavigation. In Python, a pipeline for signal processing, image registration, and coordinate transformation was set up. The Euclidian distances between the pre- and postoperative coordinates were calculated. The proposed workflow was evaluated on static references, a phantom, and three patients with suspected high-grade gliomas. In total, six biopsy samples that overlapped with the region of the highest PpIX peak without increased microcirculation were taken. The samples were confirmed as being tumorous and postoperative imaging was used to define the biopsy locations. A 2.5 ± 1.2 mm difference between the pre- and postoperative coordinates was found. Optical guidance in frameless brain tumor biopsies could offer benefits such as quantified in situ indication of high-grade tumor tissue and indications of increased blood flow along the needle trajectory before the tissue is removed. Additionally, postoperative visualization enables the combined analysis of MRI, optical, and neuropathological data.
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Affiliation(s)
- Elisabeth Klint
- Department of Biomedical Engineering, Linköping University, 581 85 Linköping, Sweden
| | - Johan Richter
- Department of Biomedical Engineering, Linköping University, 581 85 Linköping, Sweden
- Department of Neurosurgery, Linköping University Hospital, 581 85 Linköping, Sweden
| | - Karin Wårdell
- Department of Biomedical Engineering, Linköping University, 581 85 Linköping, Sweden
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Spille DC, Bunk EC, Thomas C, Özdemir Z, Wagner A, Akkurt BH, Mannil M, Paulus W, Grauer OM, Stummer W, Senner V, Brokinkel B. Protoporphyrin IX (PpIX) Fluorescence during Meningioma Surgery: Correlations with Histological Findings and Expression of Heme Pathway Molecules. Cancers (Basel) 2023; 15:cancers15010304. [PMID: 36612300 PMCID: PMC9818642 DOI: 10.3390/cancers15010304] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2022] [Revised: 12/25/2022] [Accepted: 12/28/2022] [Indexed: 01/03/2023] Open
Abstract
Background: The usefulness of 5-ALA-mediated fluorescence-guided resection (FGR) in meningiomas is controversial, and information on the molecular background of fluorescence is sparse. Methods: Specimens obtained during 44 FGRs of intracranial meningiomas were analyzed for the presence of tumor tissue and fluorescence. Protein/mRNA expression of key transmembrane transporters/enzymes involved in PpIX metabolism (ABCB6, ABCG2, FECH, CPOX) were investigated using immunohistochemistry/qPCR. Results: Intraoperative fluorescence was observed in 70 of 111 specimens (63%). No correlation was found between fluorescence and the WHO grade (p = 0.403). FGR enabled the identification of neoplastic tissue (sensitivity 84%, specificity 67%, positive and negative predictive value of 86% and 63%, respectively, AUC: 0.75, p < 0.001), and was improved in subgroup analyses excluding dura specimens (86%, 88%, 96%, 63% and 0.87, respectively; p < 0.001). No correlation was found between cortical fluorescence and tumor invasion (p = 0.351). Protein expression of ABCB6, ABCG2, FECH and CPOX was found in meningioma tissue and was correlated with fluorescence (p < 0.05, each), whereas this was not confirmed for mRNA expression. Aberrant expression was observed in the CNS. Conclusion: FGR enables the intraoperative identification of meningioma tissue with limitations concerning dura invasion and due to ectopic expression in the CNS. ABCB6, ABCG2, FECH and CPOX are expressed in meningioma tissue and are related to fluorescence.
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Affiliation(s)
- Dorothee C. Spille
- Department of Neurosurgery, University Hospital Münster, Albert-Schweitzer-Campus 1, Building A1, 48149 Münster, Germany
- Correspondence: ; Tel.: +49251-83-43959/-47472; Fax: +49251-83-45646
| | - Eva C. Bunk
- Department of Neurosurgery, University Hospital Münster, Albert-Schweitzer-Campus 1, Building A1, 48149 Münster, Germany
| | - Christian Thomas
- Institute of Neuropathology, University Hospital Münster, 48149 Münster, Germany
| | - Zeynep Özdemir
- Department of Neurosurgery, University Hospital Münster, Albert-Schweitzer-Campus 1, Building A1, 48149 Münster, Germany
| | - Andrea Wagner
- Institute of Neuropathology, University Hospital Münster, 48149 Münster, Germany
| | - Burak H. Akkurt
- Department of Radiology, University Hospital Münster, 48149 Münster, Germany
| | - Manoj Mannil
- Department of Radiology, University Hospital Münster, 48149 Münster, Germany
| | - Werner Paulus
- Institute of Neuropathology, University Hospital Münster, 48149 Münster, Germany
| | - Oliver M. Grauer
- Department of Neurology with Institute of Translational Neurology, University Hospital Münster, 48149 Münster, Germany
| | - Walter Stummer
- Department of Neurosurgery, University Hospital Münster, Albert-Schweitzer-Campus 1, Building A1, 48149 Münster, Germany
| | - Volker Senner
- Institute of Neuropathology, University Hospital Münster, 48149 Münster, Germany
| | - Benjamin Brokinkel
- Department of Neurosurgery, University Hospital Münster, Albert-Schweitzer-Campus 1, Building A1, 48149 Münster, Germany
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Ruzevick J, Cardinal T, Pangal DJ, Bove I, Strickland B, Zada G. From white to blue light: evolution of endoscope-assisted intracranial tumor neurosurgery and expansion to intraaxial tumors. J Neurosurg 2022:1-6. [PMID: 36681992 DOI: 10.3171/2022.10.jns22489] [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: 02/28/2022] [Accepted: 10/04/2022] [Indexed: 11/19/2022]
Abstract
OBJECTIVE Intraoperative use of the endoscope to assist in visualization of intracranial tumor pathology has expanded with increasing surgeon experience and improved instrumentation. The authors aimed to study how advancements in endoscopic technology have affected the evolution of endoscope use, with particular focus on blue light-filter modification allowing for discrimination of fluorescent tumor tissue following 5-ALA administration. METHODS A retrospective analysis of patients undergoing craniotomy for tumor resection at a single institution between February 2012 and July 2021 was performed. Patients were included if the endoscope was used for diagnostic tumor cavity inspection or therapeutic assistance with tumor resection following standard craniotomy and microsurgical tumor resection, with emphasis on those cases in which blue light endoscopy was used. Medical records were queried for patient demographics, operative reports describing the use of the endoscope and extent of resection, associations with tumor pathology, and postoperative outcomes. Preoperative and postoperative MR images were reviewed for radiographic extent of resection. RESULTS A total of 52 patients who underwent endoscope-assisted craniotomy for tumor were included. Thirty patients (57.7%) were men and the average age was 52.6 ± 16.1 years. Standard white light endoscopes were used for assistance with tumor resection in 28 cases (53.8%) for tumors primarily located in the ventricular system, parasellar region, and cerebellopontine angle. A blue light endoscope for detection of 5-ALA fluorescence was introduced into our practice in 2014 and subsequently used for assistance with tumor resection in 24 cases (46.2%) (intraaxial: n = 22, extraaxial: n = 2). Beyond the use of the surgical microscope as the primary visualization source, the blue light endoscope was used to directly perform additional tumor resection in 19/21 cases as a result of improved fluorescence detection as compared to the surgical microscope. No complications were associated with the use of the endoscope or with additional resection performed under white or blue light visualization. CONCLUSIONS Endoscopic assistance to visualize intracranial tumors had previously been limited to white light, assisting mostly in the visualization of extraaxial tumors confined to intraventricular and cisternal compartments. Blue light-equipped endoscopes provide improved versatility and visualization of 5-ALA fluorescing tissue beyond the capability of the surgical microscope, thereby expanding its use into the realm of intraaxial tumor resections.
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Affiliation(s)
- Jacob Ruzevick
- Department of Neurological Surgery, The University of Southern California Keck School of Medicine, Los Angeles, California
| | - Tyler Cardinal
- Department of Neurological Surgery, The University of Southern California Keck School of Medicine, Los Angeles, California
| | - Dhiraj J. Pangal
- Department of Neurological Surgery, The University of Southern California Keck School of Medicine, Los Angeles, California
| | - Ilaria Bove
- Department of Neurological Surgery, The University of Southern California Keck School of Medicine, Los Angeles, California
| | - Ben Strickland
- Department of Neurological Surgery, The University of Southern California Keck School of Medicine, Los Angeles, California
| | - Gabriel Zada
- Department of Neurological Surgery, The University of Southern California Keck School of Medicine, Los Angeles, California
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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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10
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5-Aminolevulinic acid fluorescence in brain non-neoplastic lesions: a systematic review and case series. Neurosurg Rev 2022; 45:3139-3148. [PMID: 35972631 DOI: 10.1007/s10143-022-01843-y] [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: 06/18/2022] [Revised: 08/03/2022] [Accepted: 08/08/2022] [Indexed: 10/15/2022]
Abstract
Fluorescence-guided surgery with 5-aminolevulinic acid (5-ALA) is used to assist brain tumor resection, especially for high-grade gliomas but also for low-grade gliomas, metastasis, and meningiomas. With the increasing use of this technique, even to assist biopsies, high-grade glioma-mimicking lesions had misled diagnosis by showing 5-ALA fluorescence in non-neoplastic lesions such as radiation necrosis and inflammatory or infectious disease. Since only isolated reports have been published, we systematically review papers reporting non-neoplastic lesion cases with 5-ALA according with the PRISMA guidelines, present our series, and discuss its pathophysiology. In total, 245 articles were identified and 12 were extracted according to our inclusion criteria. Analyzing 27 patients, high-grade glioma was postulated as preoperative diagnosis in 48% of the cases. Microsurgical resection was performed in 19 cases (70%), while 8 patients were submitted to biopsy (30%). We found 4 positive cases in demyelinating disease (50%), 4 in brain abscess (80%), 1 in neurocysticercosis (33%), 1 in neurotoxoplasmosis, infarction, and hematoma (100%), 4 in inflammatory disease (80%), and 3 in cortical dysplasia (100%). New indications are being considered especially in benign lesion biopsies with assistance of 5-ALA. Using fluorescence as an aid in biopsies may improve procedure time, number of samples, and necessity of intraoperative pathology. Further studies should include this technology to encourage more beneficial uses.
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11
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The NXDC-MEN-301 Study on 5-ALA for Meningiomas Surgery: An Innovative Study Design for the Assessing the Benefit of Intra-Operative Fluorescence Imaging. Brain Sci 2022; 12:brainsci12081044. [PMID: 36009108 PMCID: PMC9405714 DOI: 10.3390/brainsci12081044] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2022] [Revised: 08/03/2022] [Accepted: 08/03/2022] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND 5-aminolevulinic acid (5-ALA; GleolanTM, NX Development Corps., Lexington, USA) is approved for fluorescence-guided resections of suspected malignant gliomas. Experience has demonstrated that meningiomas also show fluorescence, which may be a useful surgical adjunct. We present an innovative design for a multi-center, prospective study to determine the clinical safety and potential benefit of fluorescence-guided resection of meningiomas with utmost bias reduction. METHODS All patients with suspected meningioma (all grades) receive GleolanTM 20 mg/kg 2-4 h prior to surgery supported by fluorescence excitation from a blue light source (Blue400, Zeiss Meditech, Oberkochen, Germany; FL400, Leica Microsystems, Heerbrugg, Switzerland). Surgeons are asked whether a residual tumor can be observed to fluoresce under blue light (BL) after the tumor is no longer recognizable using conventional illumination at the end of surgery. In addition, when faced with tissues of uncertain tissue type (so-called "indeterminate" tissue), this study records how often surgeons make a correct decision based on fluorescence and how this influences surgical strategy. The primary endpoint is the percentage of patients in whom one of these two benefits are observed. Other endpoints include the diagnostic accuracy of fluorescence compared to white light (WL) versus correlative histology. For bias reduction, pertinent data are derived from surgical videos reviewed by independent reviewers blinded to surgeons' assessments of tissue type and fluorescence status. Data will be included from approximately 100 study participants completing the study at approximately 15 centers in the United States, Germany, and Austria. RESULTS As of May 2022, 88 patients have completed the study. No adverse safety signal has been detected. CONCLUSIONS Preliminary data confirm the feasibility of our study design. Accrual is targeted for completion in the third quarter of 2022.
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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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Takeda J, Nonaka M, Li Y, Isozaki H, Kamei T, Hashiba T, Asai A. 5-Aminolevulinic acid fluorescence-guided endoscopic surgery for intraventricular tumors. Surg Neurol Int 2022; 13:302. [PMID: 35928327 PMCID: PMC9345107 DOI: 10.25259/sni_488_2022] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2022] [Accepted: 06/26/2022] [Indexed: 11/06/2022] Open
Abstract
Background: In recent years, the efficacy of 5-aminolevulinic acid photodynamic diagnosis (5-ALA PDD) has been reported for various types of brain tumors, including malignant glioma. In addition, many reports have been published on the usefulness of neuroendoscopic surgery for intraventricular lesions. However, no systematic report is available on the combined use of 5-ALA PDD and neuroendoscopy for various intraventricular tumors. Methods: We report 17 consecutive patients with intraventricular tumors. All patients received oral 5-ALA preoperatively and underwent endoscopic surgical treatment (resection or biopsy). We use a rigid endoscope with a built-in PDD system for intraoperative observation. Results: Seven resections and 10 biopsies were performed. Histopathological diagnosis was confirmed in all 17 cases. Gross total resection was achieved in six of seven cases. The fluorescence positivity rates for each tumor were glioblastoma 100% (2/2), low-grade glioma 67% (2/3), subependymoma 0% (0/1), medulloblastoma 100% (1/1), pineoblastoma 0% (0/1), germ cell tumor 75% (3/4), diffuse large B-cell lymphoma 33% (1/3), and metastatic tumor 100% (2/2). Conclusion: Our method has the potential to improve detection of residual tumors in blind spots and deep areas, as well as the accuracy and safety of biopsy procedures for intraventricular lesions that are difficult to view and treat under a microscope.
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Takase H, Yamamoto T. Bone Invasive Meningioma: Recent Advances and Therapeutic Perspectives. Front Oncol 2022; 12:895374. [PMID: 35847854 PMCID: PMC9280135 DOI: 10.3389/fonc.2022.895374] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2022] [Accepted: 06/01/2022] [Indexed: 11/13/2022] Open
Abstract
Meningioma is the most common primary neoplasm of the central nervous system (CNS). Generally, these tumors are benign and have a good prognosis. However, treatment can be challenging in cases with aggressive variants and poor prognoses. Among various prognostic factors that have been clinically investigated, bone invasion remains controversial owing to a limited number of assessments. Recent study reported that bone invasion was not associated with WHO grades, progression, or recurrence. Whereas, patients with longer-recurrence tended to have a higher incidence of bone invasion. Furthermore, bone invasion may be a primary preoperative predictor of the extent of surgical resection. Increasing such evidence highlights the potential of translational studies to understand bone invasion as a prognostic factor of meningiomas. Therefore, this mini-review summarizes recent advances in pathophysiology and diagnostic modalities and discusses future research directions and therapeutic strategies for meningiomas with bone invasion.
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Affiliation(s)
- Hajime Takase
- Center for Novel and Exploratory Clinical Trials (Y-NEXT), Yokohama City University Hospital, Yokohama, Japan
- Department of Neurosurgery, Graduate School of Medicine, Yokohama City University, Yokohama, Japan
- *Correspondence: Hajime Takase, ; orcid.org/0000-0001-5813-1386
| | - Tetsuya Yamamoto
- Department of Neurosurgery, Graduate School of Medicine, Yokohama City University, Yokohama, Japan
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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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Does pigmentation, hemosiderin and blood affect visible 5-ALA fluorescence in cerebral melanoma metastasis? Photodiagnosis Photodyn Ther 2022; 39:102864. [DOI: 10.1016/j.pdpdt.2022.102864] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Revised: 04/10/2022] [Accepted: 04/12/2022] [Indexed: 11/23/2022]
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Jiang M, Hong K, Mao Y, Ma H, Chen T, Wang Z. Natural 5-Aminolevulinic Acid: Sources, Biosynthesis, Detection and Applications. Front Bioeng Biotechnol 2022; 10:841443. [PMID: 35284403 PMCID: PMC8913508 DOI: 10.3389/fbioe.2022.841443] [Citation(s) in RCA: 25] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2021] [Accepted: 01/20/2022] [Indexed: 12/02/2022] Open
Abstract
5-Aminolevulinic acid (5-ALA) is the key precursor for the biosynthesis of tetrapyrrole compounds, with wide applications in medicine, agriculture and other burgeoning fields. Because of its potential applications and disadvantages of chemical synthesis, alternative biotechnological methods have drawn increasing attention. In this review, the recent progress in biosynthetic pathways and regulatory mechanisms of 5-ALA synthesis in biological hosts are summarized. The research progress on 5-ALA biosynthesis via the C4/C5 pathway in microbial cells is emphasized, and the corresponding biotechnological design strategies are highlighted and discussed in detail. In addition, the detection methods and applications of 5-ALA are also reviewed. Finally, perspectives on potential strategies for improving the biosynthesis of 5-ALA and understanding the related mechanisms to further promote its industrial application are conceived and proposed.
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Affiliation(s)
- Meiru Jiang
- Frontier Science Center for Synthetic Biology (Ministry of Education), Key Laboratory of Systems Bioengineering (Ministry of Education), SynBio Research Platform, Collaborative Innovation Center of Chemical Science and Engineering (Tianjin), School of Chemical Engineering and Technology, Tianjin University, Tianjin, China
| | - Kunqiang Hong
- Frontier Science Center for Synthetic Biology (Ministry of Education), Key Laboratory of Systems Bioengineering (Ministry of Education), SynBio Research Platform, Collaborative Innovation Center of Chemical Science and Engineering (Tianjin), School of Chemical Engineering and Technology, Tianjin University, Tianjin, China
| | - Yufeng Mao
- Key Laboratory of System Microbial Biotechnology, Tianjin Institute of Industrial Biotechnology, Chinese Academy of Sciences, Tianjin, China
| | - Hongwu Ma
- Key Laboratory of System Microbial Biotechnology, Tianjin Institute of Industrial Biotechnology, Chinese Academy of Sciences, Tianjin, China
| | - Tao Chen
- Frontier Science Center for Synthetic Biology (Ministry of Education), Key Laboratory of Systems Bioengineering (Ministry of Education), SynBio Research Platform, Collaborative Innovation Center of Chemical Science and Engineering (Tianjin), School of Chemical Engineering and Technology, Tianjin University, Tianjin, China
| | - Zhiwen Wang
- Frontier Science Center for Synthetic Biology (Ministry of Education), Key Laboratory of Systems Bioengineering (Ministry of Education), SynBio Research Platform, Collaborative Innovation Center of Chemical Science and Engineering (Tianjin), School of Chemical Engineering and Technology, Tianjin University, Tianjin, China
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18
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Improved Protoporphyrin IX-Guided Neurosurgical Tumor Detection with Frequency-Domain Fluorescence Lifetime Imaging. APPLIED SCIENCES-BASEL 2022. [DOI: 10.3390/app12031002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Precise intraoperative brain tumor visualization supports surgeons in achieving maximal safe resection. In this sense, improved prognosis in patients with high-grade gliomas undergoing protoporphyrin IX fluorescence-guided surgery has been demonstrated. Phase fluorescence lifetime imaging in the frequency-domain has shown promise to distinguish weak protoporphyrin IX fluorescence from competing endogenous tissue fluorophores, thus allowing for brain tumor detection with high sensitivity. In this work, we show that this technique can be further improved by minimizing the crosstalk of autofluorescence signal contributions when only detecting the fluorescence emission above 615 nm. Combining fluorescence lifetime and spectroscopic measurements on a set of 130 ex vivo brain tumor specimens (14 low- and 56 high-grade gliomas, 39 meningiomas and 21 metastases) coherently substantiated the resulting increase of the fluorescence lifetime with respect to the detection band employed in previous work. This is of major interest for obtaining a clear-cut distinction from the autofluorescence background of the physiological brain. In particular, the median fluorescence lifetime of low- and high-grade glioma specimens lacking visual fluorescence during surgical resection was increased from 4.7 ns to 5.4 ns and 2.9 ns to 3.3 ns, respectively. While more data are needed to create statistical evidence, the coherence of what was observed throughout all tumor groups emphasized that this optimization should be taken into account for future studies.
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19
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Byrd BK, Duke RB, Fan X, Wirth DJ, Warner WR, Hoopes PJ, Strawbridge RR, Evans LT, Paulsen KD, Davis SC. Whole-brain MR-registered cryo-imaging of a porcine-human glioma model to compare contrast agent biodistributions. PROCEEDINGS OF SPIE--THE INTERNATIONAL SOCIETY FOR OPTICAL ENGINEERING 2022; 11943:1194303. [PMID: 36226235 PMCID: PMC9553323 DOI: 10.1117/12.2608252] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Abstract
As rapidly accelerating technology, fluorescence guided surgery (FGS) has the potential to place molecular information directly into the surgeon's field of view by imaging administered fluorescent contrast agents in real time, circumnavigating pre-operative MR registration challenges with brain deformation. The most successful implementation of FGS is 5-ALA-PpIX guided glioma resection which has been linked to improved patient outcomes. While FGS may offer direct in-field guidance, fluorescent contrast agent distributions are not as familiar to the surgical community as Gd-MRI uptake, and may provide discordant information from previous Gd-MRI guidance. Thus, a method to assess and validate consistency between fluorescence-labeled tumor regions and Gd-enhanced tumor regions could aid in understanding the correlation between optical agent fluorescence and Gd-enhancement. Herein, we present an approach for comparing whole-brain fluorescence biodistributions with Gd-enhancement patterns on a voxel-by-voxel basis using co-registered fluorescent cryo-volumes and Gd-MRI volumes. In this initial study, a porcine-human glioma xenograft model was administered 5-ALA-PpIX, imaged with MRI, and euthanized 22 hours following 5-ALA administration. Following euthanization, the extracted brain was imaged with the cryo-macrotome system. After image processing steps and non-rigid, point-based registration, the fluorescence cryo-volume and Gd-MRI volume were compared for similarity metrics including: image similarity, tumor shape similarity, and classification similarity. This study serves as a proof-of-principle in validating our screening approach for quantitatively comparing 3D biodistributions between optical agents and Gd-based agents.
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Affiliation(s)
- B K Byrd
- Thayer School of Engineering at Dartmouth College, 14 Engineering Dr. Hanover, NH, 03755
| | - R B Duke
- Thayer School of Engineering at Dartmouth College, 14 Engineering Dr. Hanover, NH, 03755
| | - X Fan
- Thayer School of Engineering at Dartmouth College, 14 Engineering Dr. Hanover, NH, 03755
| | - D J Wirth
- Thayer School of Engineering at Dartmouth College, 14 Engineering Dr. Hanover, NH, 03755
| | - W R Warner
- Thayer School of Engineering at Dartmouth College, 14 Engineering Dr. Hanover, NH, 03755
| | - P J Hoopes
- Thayer School of Engineering at Dartmouth College, 14 Engineering Dr. Hanover, NH, 03755
| | - R R Strawbridge
- Thayer School of Engineering at Dartmouth College, 14 Engineering Dr. Hanover, NH, 03755
| | - L T Evans
- Thayer School of Engineering at Dartmouth College, 14 Engineering Dr. Hanover, NH, 03755
| | - K D Paulsen
- Thayer School of Engineering at Dartmouth College, 14 Engineering Dr. Hanover, NH, 03755
| | - S C Davis
- Thayer School of Engineering at Dartmouth College, 14 Engineering Dr. Hanover, NH, 03755
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20
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Stimulation and homogenization of the protoporphyrin IX endogenous production by photobiomodulation to increase the potency of photodynamic therapy. JOURNAL OF PHOTOCHEMISTRY AND PHOTOBIOLOGY B-BIOLOGY 2021; 225:112347. [PMID: 34736068 DOI: 10.1016/j.jphotobiol.2021.112347] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/07/2021] [Revised: 10/21/2021] [Accepted: 10/25/2021] [Indexed: 12/20/2022]
Abstract
Protoporphyrin IX (PpIX) is produced in the mitochondria and used as fluorescent contrast agent or photosensitizer after exogenous 5-aminolevulinic acid (ALA) delivery in cancer photodynamic detection and therapy (PDT). Although routinely used in the clinics, the stimulated production of PpIX is often insufficient and/or heterogeneous within the lesions, thereby limiting the PDT performances. Since photobiomodulation, which is based on the illumination of the tissues with sub-thermal radiometric conditions in the red or near-infrared, is known to stimulate the cell metabolism, we have optimized these conditions in vitro. Some of them lead to the homogenization and strong stimulation of the PpIX endogenous production. Interestingly, combined sequentially, PBM enhanced significantly the potency of PpIX-based PDT in vitro and in vivo in tumors grown on the chicken embryo chorioallantoic membrane. These results are in excellent agreement with other assays based on measurements of the cell survival/death, the production of reactive oxygen species, including singlet oxygen, and the mitochondrial membrane potential.
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21
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Micko A, Rapoport BI, Youngerman BE, Fong RP, Kosty J, Brunswick A, Shahrestani S, Zada G, Schwartz TH. Limited utility of 5-ALA optical fluorescence in endoscopic endonasal skull base surgery: a multicenter retrospective study. J Neurosurg 2021; 135:535-541. [PMID: 33126212 DOI: 10.3171/2020.5.jns201171] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2020] [Accepted: 05/18/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Incomplete resection of skull base pathology may result in local tumor recurrence. This study investigates the utility of 5-aminolevulinic acid (5-ALA) fluorescence during endoscopic endonasal approaches (EEAs) to increase visibility of pathologic tissue. METHODS This retrospective multicenter series comprises patients with planned resection of an anterior skull base lesion who received preoperative 5-ALA at two tertiary care centers. Diagnostic use of a blue light endoscope was performed during EEA for all cases. Demographic and tumor characteristics as well as fluorescence status, quality, and homogeneity were assessed for each skull base pathology. RESULTS Twenty-eight skull base pathologies underwent blue-light EEA with preoperative 5-ALA, including 15 pituitary adenomas (54%), 4 meningiomas (14%), 3 craniopharyngiomas (11%), 2 Rathke's cleft cysts (7%), as well as plasmacytoma, esthesioneuroblastoma, and sinonasal squamous cell carcinoma. Of these, 6 (21%) of 28 showed invasive growth into surrounding structures such as dura, bone, or compartments of the cavernous sinus. Tumor fluorescence was detected in 2 cases (7%), with strong fluorescence in 1 tuberculum sellae meningioma and vague fluorescence in 1 pituicytoma. In all other cases fluorescence was absent. Faint fluorescence of the normal pituitary gland was seen in 1 (7%) of 15 cases. A comparison between the particular tumor entities as well as a correlation between invasiveness, WHO grade, Ki-67, and positive fluorescence did not show any significant association. CONCLUSIONS With the possible exception of meningiomas, 5-ALA fluorescence has limited utility in the majority of endonasal skull base surgeries, although other pathology may be worth investigating.
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Affiliation(s)
- Alexander Micko
- 1Department of Neurosurgery, Medical University of Vienna, Austria
- 2Department of Neurosurgery, Keck School of Medicine, University of Southern California, Los Angeles, California; and
| | - Benjamin I Rapoport
- 3Department of Neurological Surgery, NewYork-Presbyterian Hospital/Weill Cornell Medicine, New York, New York
| | - Brett E Youngerman
- 3Department of Neurological Surgery, NewYork-Presbyterian Hospital/Weill Cornell Medicine, New York, New York
| | - Reginald P Fong
- 3Department of Neurological Surgery, NewYork-Presbyterian Hospital/Weill Cornell Medicine, New York, New York
| | - Jennifer Kosty
- 3Department of Neurological Surgery, NewYork-Presbyterian Hospital/Weill Cornell Medicine, New York, New York
| | - Andrew Brunswick
- 2Department of Neurosurgery, Keck School of Medicine, University of Southern California, Los Angeles, California; and
| | - Shane Shahrestani
- 2Department of Neurosurgery, Keck School of Medicine, University of Southern California, Los Angeles, California; and
| | - Gabriel Zada
- 2Department of Neurosurgery, Keck School of Medicine, University of Southern California, Los Angeles, California; and
| | - Theodore H Schwartz
- 3Department of Neurological Surgery, NewYork-Presbyterian Hospital/Weill Cornell Medicine, New York, New York
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22
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Recinos PF. Editorial. Is the use of 5-ALA in endoscopic skull base surgery truly limited or in need of more refined evaluation? J Neurosurg 2021; 135:532-533. [PMID: 33126207 DOI: 10.3171/2020.7.jns201870] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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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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Let Me See: Correlation between 5-ALA Fluorescence and Molecular Pathways in Glioblastoma: A Single Center Experience. Brain Sci 2021; 11:brainsci11060795. [PMID: 34208653 PMCID: PMC8235669 DOI: 10.3390/brainsci11060795] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2021] [Revised: 06/04/2021] [Accepted: 06/10/2021] [Indexed: 11/17/2022] Open
Abstract
Background: Despite the aggressiveness of multimodal treatment, glioblastoma (GBM) is still a challenge for neurosurgeons, neurooncologists, and radiotherapists. A surgical approach is still a cornerstone in GBM therapeutic management, as the extent of resection is strongly related both to overall survival and progression-free survival. From this perspective, the use of photodynamic molecules could represent an interesting tool to achieve maximal and safe resection. Being able to trace the lesion’s edges, indeed, could allow to improve the extent of resection and to minimize residual tumor while sparing normal tissue. The use of 5-aminolevulinic acid (5-ALA) as a photodynamic tracer is well established due to its strict correlation both with cellularity and metabolic activity of the GBM cell clones. Objective: Our study aims to define whether a different molecular asset of GBM (especially investigating IDH 1/2 mutation, proliferation index, and MGMT promoter methylation) results in different fluorescence expression, possibly because of differences in metabolic pathways due to different genotypes. Methods: Patients undergoing surgery for GBM removal at our Institute (Dep. Of Neurosurgery, Ospedale Città della Salute e della Scienza, University of Turin, Italy) were retrospectively reviewed. Patients with histological diagnosis confirmation and to whom 5-ALA was given before surgery were included. The whole surgical procedure was recorded and then analyzed by three different people (a medical student, a resident, and a senior surgeon with an interest in neurooncology and experience in using 5-ALA) and a score was assigned to the different degrees of intraoperative fluorescence. The degree of fluorescence was then matched with the genotype. Results: A trend of grade 2 fluorescence (i.e., ”strong”) was observed in the IDH 1/2 wild-type (WT) genotype, suggesting a more intense metabolic activity in this particular subgroup, while, no or weak fluorescence was observed more often in the IDH 1/2 mutated tumors, suggesting a lower metabolic activity. No relations were found between fluorescence grade and MGMT promoter methylation or, interestingly, cellularity. As a secondary analysis, more epileptogenicity of the IDH 1/2 mutated GBM was noticed, similarly to other recent literature. Conclusion: Our results do not support the use of 5-ALA as a diagnostic tool, or a way to substitute the molecular profiling, but confirm 5-ALA as a powerful metabolic tracer, able to easily detect the pathological cells, especially in the IDH WT genotype, and in this perspective, further studies will be necessary to better describe the metabolic activity of GBM cells.
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Fluorescence image-guided resection of intracranial meningioma: an experimental in vivo study on nude mice. Ann Anat 2021; 237:151752. [PMID: 33940118 DOI: 10.1016/j.aanat.2021.151752] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2021] [Revised: 04/12/2021] [Accepted: 04/13/2021] [Indexed: 12/21/2022]
Abstract
INTRODUCTION The use of photodynamic agents in malignant cranial tumor surgery is quite common. For example five-aminolevulinic acid (5-ALA)-induced porphyrins in malignant gliomas are potent photosensitizers. Until today there is no comparable selective fluorescent substance available for meningiomas. Nevertheless, there is a demand for intraoperative fluorescent identification of e.g. invasive skull base meningiomas to increase radicality. This study was established to investigate fluorescent image-guided resection with somatostatin receptor labelled fluorescence dye for intracranial meningioma in the nude mice. METHODS Primary meningioma cell culture samples were stereotactically implanted subdural into 20 nude mice. 90 days after inoculation of the cells, a cranial MRI with contrast agent revealed tumor growth. After detection of tumor mass in MRI, FAM-TOC5,6-Carboxyfluoresceine-Tyr3-Octreotide was injected intravenously and tumor mass was hereafter resected under visualization via fluorescence microscope and endoscope. After attempted total resection, animal were sacrificed brain slices were obtained and histologically analysed to verify the resection extent. RESULTS In 18 mice tumor growth was detected in MRI after 90 days of inoculation. The tumor mass could be clearly identified with fluorescence microscope and endoscope after injecting FAM-TOC5,6-Carboxyfluoresceine-Tyr3-Octreotide. The tumor margins could be better visualized. After fluorescence-guided resection no remaining tumor could be identified in histological analysis. CONCLUSIONS This study describes for the first time the use of FAM-TOC5,6-Carboxyfluoresceine-Tyr3-Octreotide and demonstrates its value of fluorescent identification of meningioma cells in vivo. Furthermore, the authors established a new experimental animal model for fluorescence meningioma surgery.
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Millesi M, Kiesel B, Mazanec V, Wadiura LI, Wöhrer A, Herta J, Wolfsberger S, Novak K, Furtner J, Rössler K, Knosp E, Widhalm G. 5-ALA fluorescence for intraoperative visualization of spinal ependymal tumors and identification of unexpected residual tumor tissue: experience in 31 patients. J Neurosurg Spine 2021; 34:374-382. [PMID: 33276339 DOI: 10.3171/2020.6.spine20506] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2020] [Accepted: 06/29/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Gross-total resection (GTR) is the treatment of choice in the majority of patients suffering from spinal ependymal tumors. In such tumors, the extent of resection (EOR) is considered the key factor for tumor recurrence and thus patient prognosis. However, incomplete resection is not uncommon and leads to increased risk of tumor recurrence. One important cause of incomplete resection is insufficient intraoperative visualization of tumor tissue as well as residual tumor tissue. Therefore, the authors investigated the value of 5-aminolevulinic acid (5-ALA)-induced fluorescence in a series of spinal ependymal tumors for improved tumor visualization. METHODS Adult patients who underwent preoperative 5-ALA administration and surgery for a spinal ependymal tumor were included in this study. For each tumor, a conventional white-light microsurgical resection was performed. Additionally, the fluorescence status (strong, vague, or no fluorescence) and fluorescence homogeneity (homogenous or inhomogeneous) of the spinal ependymal tumors were evaluated during surgery using a modified neurosurgical microscope. In intramedullary tumor cases with assumed GTR, the resection cavity was investigated for potential residual fluorescing foci under white-light microscopy. In cases with residual fluorescing foci, these areas were safely resected and the corresponding samples were histopathologically screened for the presence of tumor tissue. RESULTS In total, 31 spinal ependymal tumors, including 27 intramedullary tumors and 4 intradural extramedullary tumors, were included in this study. Visible fluorescence was observed in the majority of spinal ependymal tumors (n = 25, 81%). Of those, strong fluorescence was noted in 23 of these cases (92%), whereas vague fluorescence was present in 2 cases (8%). In contrast, no fluorescence was observed in the remaining 6 tumors (19%). Most ependymal tumors demonstrated an inhomogeneous fluorescence effect (17 of 25 cases, 68%). After assumed GTR in intramedullary tumors (n = 15), unexpected residual fluorescing foci within the resection cavity could be detected in 5 tumors (33%). These residual fluorescing foci histopathologically corresponded to residual tumor tissue in all cases. CONCLUSIONS This study indicates that 5-ALA fluorescence makes it possible to visualize the majority of spinal ependymal tumors during surgery. Unexpected residual tumor tissue could be detected with the assistance of 5-ALA fluorescence in approximately one-third of analyzed intramedullary tumors. Thus, 5-ALA fluorescence might be useful to increase the EOR, particularly in intramedullary ependymal tumors, in order to reduce the risk of tumor recurrence.
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Affiliation(s)
- Matthias Millesi
- 1Department of Neurosurgery
- 4Comprehensive Cancer Center-Central Nervous System Tumours Unit (CCC-CNS), Medical University of Vienna, Austria
| | - Barbara Kiesel
- 1Department of Neurosurgery
- 4Comprehensive Cancer Center-Central Nervous System Tumours Unit (CCC-CNS), Medical University of Vienna, Austria
| | - Vanessa Mazanec
- 1Department of Neurosurgery
- 4Comprehensive Cancer Center-Central Nervous System Tumours Unit (CCC-CNS), Medical University of Vienna, Austria
| | - Lisa I Wadiura
- 1Department of Neurosurgery
- 4Comprehensive Cancer Center-Central Nervous System Tumours Unit (CCC-CNS), Medical University of Vienna, Austria
| | - Adelheid Wöhrer
- 2Division of Neuropathology and Neurochemistry, Department of Neurology
- 4Comprehensive Cancer Center-Central Nervous System Tumours Unit (CCC-CNS), Medical University of Vienna, Austria
| | | | - Stefan Wolfsberger
- 1Department of Neurosurgery
- 4Comprehensive Cancer Center-Central Nervous System Tumours Unit (CCC-CNS), Medical University of Vienna, Austria
| | | | - Julia Furtner
- 3Department of Biomedical Imaging and Image-Guided Therapy; and
- 4Comprehensive Cancer Center-Central Nervous System Tumours Unit (CCC-CNS), Medical University of Vienna, Austria
| | - Karl Rössler
- 1Department of Neurosurgery
- 4Comprehensive Cancer Center-Central Nervous System Tumours Unit (CCC-CNS), Medical University of Vienna, Austria
| | - Engelbert Knosp
- 1Department of Neurosurgery
- 4Comprehensive Cancer Center-Central Nervous System Tumours Unit (CCC-CNS), Medical University of Vienna, Austria
| | - Georg Widhalm
- 1Department of Neurosurgery
- 4Comprehensive Cancer Center-Central Nervous System Tumours Unit (CCC-CNS), Medical University of Vienna, Austria
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5-ALA kinetics in meningiomas: analysis of tumor fluorescence and PpIX metabolism in vitro and comparative analyses with high-grade gliomas. J Neurooncol 2021; 152:37-46. [PMID: 33389565 DOI: 10.1007/s11060-020-03680-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2020] [Accepted: 12/12/2020] [Indexed: 10/22/2022]
Abstract
INTRODUCTION Although the utility 5-aminolevulinic acid (5-ALA)-mediated fluorescence-guided surgery (FGS) in meningiomas is increasingly discussed, data about the kinetics of protoporphyrin IX (PpIX) and tumor fluorescence are sparse. METHODS PpIX kinetics after exposition to varying 5-ALA doses (12.5-150 µg/ml) was analyzed in two immortalized as well as primary WHO grade I and II meningioma and U87 high-grade glioma cell lines. Expression of FECH, ABCB6 and ABCG2 was investigated by quantitative real-time PCR. RESULTS Fluorescence in Ben-Men 1 and primary WHO grade I/II meningioma increased with rising 5-ALA doses up to 100 µg/ml but then showed a saturation effect. However, decrease of fluorescence was slower after 150 than after 100 µg/ml 5-ALA. Fluorescence in U87 cells marginally increased with rising 5-ALA doses. Kinetics of the fluorescence in Ben-Men 1 cells did not differ from primary meningioma cells after 25-150 µg/ml 5-ALA (p > .05, each). No difference was found when comparing the fluorescence between primary grade I and II meningiomas after any 5-ALA dosage (p > .05, each). No relevant fluorescence was found in IOMM-Lee cells. Expression of FECH, ABCB6 and ABCG2 as well as PpIX export differed between all analyzed cell lines but were not connected to fluorescence. CONCLUSIONS Eligibility of established meningioma cell lines for in-vitro analyzes of tumor fluorescence significantly differs. Fluorescence in Ben-Men 1 and primary meningioma cell lines but less in IOMM Lee cells is 5-ALA dose-dependent, encouraging in-situ trials to encounter currently discussed shortcomings of FGS in meningiomas. Fluorescence is not related to expression of FECH, ABCB6 and ABCG2.
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CNS Invasion in Meningioma-How the Intraoperative Assessment Can Improve the Prognostic Evaluation of Tumor Recurrence. Cancers (Basel) 2020; 12:cancers12123620. [PMID: 33287241 PMCID: PMC7761660 DOI: 10.3390/cancers12123620] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2020] [Revised: 11/26/2020] [Accepted: 11/30/2020] [Indexed: 11/22/2022] Open
Abstract
Simple Summary Brain invasion has been integrated into the new WHO classification of meningiomas to improve the prognostic assessment regarding tumor recurrence. However, its role has been questioned. One of the reasons is that for complete histopathological assessment, tissue sampling of the complete brain–tumor interface is necessary, but not always surgically and technically feasible. Therefore, the additional intraoperative assessment of CNS invasion may be of value for a more precise assessment of this tumor characteristic. We therefore studied the prognostic impact of the histopathological and intraoperative assessment of CNS invasion regarding radiographic tumor recurrence and found that both factors by themselves do not reach a prognostic significance. However, if both factors are combined, CNS invasion is an independent negative prognostic factor. Our findings show the prognostic potential of a thorough assessment and underline the need for a standardization and documentation of meningioma tissue sampling for the optimal recurrence risk assessment. Abstract The detection of the infiltrative growth of meningiomas into CNS tissue has been integrated into the WHO classification as a stand-alone marker for atypical meningioma. However, its prognostic impact has been questioned. Infiltrative growth can also be detected intraoperatively. The prognostic impact of the intraoperative detection of the central nervous system tissue invasion of meningiomas was analyzed and compared to the histopathological assessment. The clinical data of 1517 cases with follow-up data regarding radiographic recurrence was collected. Histopathology and operative reports were reviewed and invasive growth was seen during resection in 23.7% (n = 345) while histopathology detected it in 4.8% (n = 73). The histopathological and intraoperative assessments were compatible in 63%. The prognostic impact of histopathological and intraoperative assessment was significant in the univariate but not in the multivariate analysis. Both methods of assessment combined reached statistical significance in the multivariate analysis (p = 0.0409). A score including all independent prognostic factors divided the cohort into three prognostic subgroups with a risk of recurrence of 33.8, 64.7 and 88.5%, respectively. The intraoperative detection of the infiltrative growth of primary meningiomas into the central nervous system tissue can complement the histopathological assessment of CNS invasion. The combined assessment is an independent prognostic factor regarding tumor recurrence and allows a risk-adapted tumor stratification.
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Marhold F, Mercea PA, Scheichel F, Berghoff AS, Heicappell P, Kiesel B, Mischkulnig M, Borkovec M, Wolfsberger S, Woehrer A, Preusser M, Knosp E, Ungersboeck K, Widhalm G. Detailed analysis of 5-aminolevulinic acid induced fluorescence in different brain metastases at two specialized neurosurgical centers: experience in 157 cases. J Neurosurg 2020; 133:1032-1043. [PMID: 31561223 DOI: 10.3171/2019.6.jns1997] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2019] [Accepted: 06/13/2019] [Indexed: 01/02/2023]
Abstract
OBJECTIVE Incomplete neurosurgical resection of brain metastases (BM) due to insufficient intraoperative visualization of tumor tissue is a major clinical challenge and might result in local recurrence. Recently, visible 5-aminolevulinic acid (5-ALA) induced fluorescence was first reported in patients with BM. The aim of this study was thus to investigate, for the first time systematically, the value of 5-ALA fluorescence for intraoperative visualization of BM in a large patient cohort. METHODS Adult patients (≥ 18 years) with resection of suspected BM after preoperative 5-ALA administration were prospectively recruited at two specialized neurosurgical centers. During surgery, the fluorescence status (visible or no fluorescence); fluorescence quality (strong, vague, or none); and fluorescence homogeneity (homogeneous or heterogeneous) of each BM was investigated. Additionally, these specific fluorescence characteristics of BM were correlated with the primary tumor type and the histopathological subtype. Tumor diagnosis was established according to the current WHO 2016 criteria. RESULTS Altogether, 157 BM were surgically treated in 154 patients. Visible fluorescence was observed in 104 BM (66%), whereas fluorescence was absent in the remaining 53 cases (34%). In detail, 53 tumors (34%) showed strong fluorescence, 51 tumors (32%) showed vague fluorescence, and 53 tumors (34%) had no fluorescence. The majority of BM (84% of cases) demonstrated a heterogeneous fluorescence pattern. According to primary tumor, visible fluorescence was less frequent in BM of melanomas compared to all other tumors (p = 0.037). According to histopathological subtype, visible fluorescence was more common in BM of ductal breast cancer than all other subtypes (p = 0.008). It is of note that visible fluorescence was observed in the surrounding brain tissue after the resection of BM in 74 (67%) of 111 investigated cases as well. CONCLUSIONS In this largest series to date, visible 5-ALA fluorescence was detected in two-thirds of BM. However, the characteristic heterogeneous fluorescence pattern and frequent lack of strong fluorescence limits the use of 5-ALA in BM and thus this technique needs further improvements.
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Affiliation(s)
- Franz Marhold
- 1Department of Neurosurgery, University Hospital St. Pölten, Karl Landsteiner University of Health Sciences, St. Pölten, Austria
| | - Petra A Mercea
- 2Department of Neurosurgery, Medical University of Vienna, Austria
| | - Florian Scheichel
- 1Department of Neurosurgery, University Hospital St. Pölten, Karl Landsteiner University of Health Sciences, St. Pölten, Austria
| | - Anna S Berghoff
- 3Clinical Division of Oncology, Department of Medicine I, Medical University of Vienna, Austria
- 6Comprehensive Cancer Center-Central Nervous System Tumours Unit, Medical University of Vienna, Austria
| | - Patricia Heicappell
- 3Clinical Division of Oncology, Department of Medicine I, Medical University of Vienna, Austria
- 6Comprehensive Cancer Center-Central Nervous System Tumours Unit, Medical University of Vienna, Austria
| | - Barbara Kiesel
- 2Department of Neurosurgery, Medical University of Vienna, Austria
- 6Comprehensive Cancer Center-Central Nervous System Tumours Unit, Medical University of Vienna, Austria
| | | | - Martin Borkovec
- 4Department of Statistics, Ludwig-Maximilians-Universität Munich, Germany
| | - Stefan Wolfsberger
- 2Department of Neurosurgery, Medical University of Vienna, Austria
- 6Comprehensive Cancer Center-Central Nervous System Tumours Unit, Medical University of Vienna, Austria
| | - Adelheid Woehrer
- 5Institute of Neurology, Medical University of Vienna, Austria; and
- 6Comprehensive Cancer Center-Central Nervous System Tumours Unit, Medical University of Vienna, Austria
| | - Matthias Preusser
- 3Clinical Division of Oncology, Department of Medicine I, Medical University of Vienna, Austria
- 6Comprehensive Cancer Center-Central Nervous System Tumours Unit, Medical University of Vienna, Austria
| | - Engelbert Knosp
- 2Department of Neurosurgery, Medical University of Vienna, Austria
- 6Comprehensive Cancer Center-Central Nervous System Tumours Unit, Medical University of Vienna, Austria
| | - Karl Ungersboeck
- 1Department of Neurosurgery, University Hospital St. Pölten, Karl Landsteiner University of Health Sciences, St. Pölten, Austria
| | - Georg Widhalm
- 2Department of Neurosurgery, Medical University of Vienna, Austria
- 6Comprehensive Cancer Center-Central Nervous System Tumours Unit, Medical University of Vienna, Austria
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Abstract
In neurosurgery, the extent of resection plays a critical role, especially in the management of malignant gliomas. These tumors are characterized through a diffuse infiltration into the surrounding brain parenchyma. Delineation between tumor and normal brain parenchyma can therefore often be challenging. During the recent years, several techniques, aiming at better intraoperative tumor visualization, have been developed and implemented in the field of brain tumor surgery. In this chapter, we discuss current strategies for intraoperative imaging in brain tumor surgery, comprising conventional techniques such as neuronavigation, techniques using fluorescence-guided surgery, and further highly precise developments such as targeted fluorescence spectroscopy or Raman spectroscopy.
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Affiliation(s)
- Stephanie Schipmann-Miletić
- Department of Neurosurgery, University Hospital Münster, Albert-Schweitzer-Campus 1, Building A1, 48149, Münster, Germany.
| | - Walter Stummer
- Department of Neurosurgery, University Hospital Münster, Albert-Schweitzer-Campus 1, Building A1, 48149, Münster, Germany
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Kaneko S, Brokinkel B, Suero Molina E, Warneke N, Holling M, Bunk EC, Hess K, Senner V, Paulus W, Stummer W. Real-time in vivo kinetics of protoporphyrin IX after administration of 5-aminolevulinic acid in meningiomas and comparative analyses with glioblastomas. Acta Neurochir (Wien) 2020; 162:2197-2202. [PMID: 32361907 DOI: 10.1007/s00701-020-04353-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2020] [Accepted: 04/14/2020] [Indexed: 11/26/2022]
Abstract
BACKGROUND The usefulness of 5-aminolevulinic acid (5-ALA)-mediated fluorescence-guided surgery (FGS) in meningiomas is intensely discussed. However, data about kinetics of 5-ALA and protoporphyrin (Pp) IX in meningiomas are lacking. METHODS As the first study so far, we performed longitudinal intraoperative real-time ex situ measurements of fluorescence intensity and PpIX concentrations during FGS of ten benign and two atypical meningiomas. Kinetics were subsequently compared with data from 229 glioblastomas. RESULTS Spectroscopy revealed fluorescence (median 2945.65 a.u.) and PpIX accumulation (median 18.31 μg/ml) in all 43 analyzed samples. Fluorescence intensity (2961.50 a.u. vs 118.41 a.u.; p < .001) and PpIX concentrations (18.72 μg/ml vs .98 μg/ml; p < .001) were higher in samples with (N = 30) than without (N = 2) visible intraoperative tumor fluorescence. ROC curve analyses revealed a PpIX cut-off concentration of 3.85 μg/ml (AUC = .992, p = .005) and a quantitative fluorescence cut-off intensity of 286.73 a.u. (AUC = .983, p = .006) for intraoperative visible tumor fluorescence. Neither fluorescence intensity (p = .356) nor PpIX (p = .631) differed between atypical and benign meningiomas. Fluorescence and PpIX peaked 7-8 h following administration of 5-ALA. Meningiomas displayed a higher fluorescence intensity (p = .012) and PpIX concentration (p = .005) than glioblastomas 5-6 h after administration of 5-ALA. Although fluorescence was basically maintained, PpIX appeared to be cleared faster in meningiomas than in glioblastomas. CONCLUSIONS Kinetics of PpIX and fluorescence intensity differ between meningiomas and glioblastomas in the early phase after 5-ALA administration. Modification of the timing of drug administration might impact visibility of intraoperative fluorescence and helpfulness of FGS and should be investigated in future analyses.
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Affiliation(s)
- Sadahiro Kaneko
- Department of Neurosurgery, University Hospital Münster, Münster, Germany
- Department of Neurosurgery, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Benjamin Brokinkel
- Department of Neurosurgery, University Hospital Münster, Münster, Germany.
| | - Eric Suero Molina
- Department of Neurosurgery, University Hospital Münster, Münster, Germany
| | - Nils Warneke
- Department of Neurosurgery, University Hospital Münster, Münster, Germany
| | - Markus Holling
- Department of Neurosurgery, University Hospital Münster, Münster, Germany
| | - Eva Christina Bunk
- Department of Neurosurgery, University Hospital Münster, Münster, Germany
| | - Katharina Hess
- Institute of Neuropathology, University Hospital Münster, Münster, Germany
| | - Volker Senner
- Institute of Neuropathology, University Hospital Münster, Münster, Germany
| | - Werner Paulus
- Institute of Neuropathology, University Hospital Münster, Münster, Germany
| | - Walter Stummer
- Department of Neurosurgery, University Hospital Münster, Münster, Germany
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Wadiura LI, Millesi M, Makolli J, Wais J, Kiesel B, Mischkulnig M, Mercea PA, Roetzer T, Knosp E, Rössler K, Widhalm G. High Diagnostic Accuracy of Visible 5-ALA Fluorescence in Meningioma Surgery According to Histopathological Analysis of Tumor Bulk and Peritumoral Tissue. Lasers Surg Med 2020; 53:300-308. [PMID: 32608510 PMCID: PMC8048546 DOI: 10.1002/lsm.23294] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Revised: 06/16/2020] [Accepted: 06/18/2020] [Indexed: 01/01/2023]
Abstract
Background and Objectives Complete neurosurgical resection of intracranial meningiomas is essential to avoid residual tumor tissue and thus minimize the risk of tumor recurrence. However, local recurrence of meningiomas is not uncommon mainly due to insufficient intraoperative detection of residual tumor tissue within the tumor bulk or peritumoral tissue such as bone and satellite lesions. Although 5‐aminolevulinic acid (5‐ALA) induced fluorescence was found to visualize the majority of meningiomas, no comprehensive histopathological assessment of fluorescing samples from the tumor bulk and peritumoral tissue is available. The aim of our study was thus to histopathologically analyze a large series of tissue samples derived from meningioma surgery to assess the positive predictive value (PPV) of visible 5‐ALA fluorescence. Study Design/Materials and Methods In this study, we retrospectively investigated a series of tissue samples with visible 5‐ALA fluorescence collected during surgery of intracranial meningiomas from the tumor bulk and peritumoral tissue including the bone flap, dura/dural tail, arachnoidea, adjacent cortex, and satellite lesions. The tumor diagnosis was established according to the World Health Organization (WHO) criteria and all collected fluorescing samples were screened for presence of tumor tissue to calculate the PPV. Results Altogether, 191 tissue samples with visible 5‐ALA fluorescence derived during surgery of 85 meningiomas (63 WHO grade I, 17 WHO grade II, and 5 WHO grade III) were included. In detail, 158 samples from the tumor bulk and 33 specimens from the peritumoral tissue were investigated. According to histopathological analysis, the PPV of 5‐ALA fluorescence was significantly higher in samples from the tumor bulk (100%) as compared with peritumoral tissue (73%; P < 0.001). With regard to peritumoral tissue, tumor tissue was present in most fluorescing samples from the satellite lesions (100%), the bone flap (92%), arachnoidea (83%), and dura/dural tail (75%). In contrast, tumor tissue was absent in the majority of samples from fluorescing cortex (six of seven samples; 86%). However, distinct reactive tissue alterations were found in all six tumor‐free fluorescing cortex samples and additional vascular proliferation in two cases. Conclusion In this largest series to date, visible 5‐ALA fluorescence is characterized by a high PPV detecting tumor bulk and peritumoral tissue in intracranial meningiomas. Thus, 5‐ALA fluorescence supports the neurosurgeon in identifying residual tumor tissue at relevant surgical sites to optimize meningioma surgery and minimize the risk of local recurrence. © 2020 The Authors. Lasers in Surgery and Medicine published by Wiley Periodicals LLC
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Affiliation(s)
- Lisa I Wadiura
- Department of Neurosurgery, Medical University Vienna, Waehringer Gürtel 18-20, Vienna, 1090, Austria.,Comprehensive Cancer Center, Central Nervous System Tumours Unit (CCC-CNS), Medical University Vienna, Spitalgasse 23, BT86/E 01, Vienna, 1090, Austria
| | - Matthias Millesi
- Department of Neurosurgery, Medical University Vienna, Waehringer Gürtel 18-20, Vienna, 1090, Austria.,Comprehensive Cancer Center, Central Nervous System Tumours Unit (CCC-CNS), Medical University Vienna, Spitalgasse 23, BT86/E 01, Vienna, 1090, Austria
| | - Jessica Makolli
- Department of Neurosurgery, Medical University Vienna, Waehringer Gürtel 18-20, Vienna, 1090, Austria
| | - Jonathan Wais
- Department of Neurosurgery, Medical University Vienna, Waehringer Gürtel 18-20, Vienna, 1090, Austria.,Comprehensive Cancer Center, Central Nervous System Tumours Unit (CCC-CNS), Medical University Vienna, Spitalgasse 23, BT86/E 01, Vienna, 1090, Austria
| | - Barbara Kiesel
- Department of Neurosurgery, Medical University Vienna, Waehringer Gürtel 18-20, Vienna, 1090, Austria.,Comprehensive Cancer Center, Central Nervous System Tumours Unit (CCC-CNS), Medical University Vienna, Spitalgasse 23, BT86/E 01, Vienna, 1090, Austria
| | - Mario Mischkulnig
- Department of Neurosurgery, Medical University Vienna, Waehringer Gürtel 18-20, Vienna, 1090, Austria.,Comprehensive Cancer Center, Central Nervous System Tumours Unit (CCC-CNS), Medical University Vienna, Spitalgasse 23, BT86/E 01, Vienna, 1090, Austria
| | - Petra A Mercea
- Department of Neurosurgery, Medical University Vienna, Waehringer Gürtel 18-20, Vienna, 1090, Austria.,Comprehensive Cancer Center, Central Nervous System Tumours Unit (CCC-CNS), Medical University Vienna, Spitalgasse 23, BT86/E 01, Vienna, 1090, Austria
| | - Thomas Roetzer
- Comprehensive Cancer Center, Central Nervous System Tumours Unit (CCC-CNS), Medical University Vienna, Spitalgasse 23, BT86/E 01, Vienna, 1090, Austria.,Department of Neurology, Division of Neuropathology and Neurochemistry, Medical University of Vienna, Waehringer Gürtel 18-20, Vienna, 1090, Austria
| | - Engelbert Knosp
- Department of Neurosurgery, Medical University Vienna, Waehringer Gürtel 18-20, Vienna, 1090, Austria.,Comprehensive Cancer Center, Central Nervous System Tumours Unit (CCC-CNS), Medical University Vienna, Spitalgasse 23, BT86/E 01, Vienna, 1090, Austria
| | - Karl Rössler
- Department of Neurosurgery, Medical University Vienna, Waehringer Gürtel 18-20, Vienna, 1090, Austria.,Comprehensive Cancer Center, Central Nervous System Tumours Unit (CCC-CNS), Medical University Vienna, Spitalgasse 23, BT86/E 01, Vienna, 1090, Austria
| | - Georg Widhalm
- Department of Neurosurgery, Medical University Vienna, Waehringer Gürtel 18-20, Vienna, 1090, Austria.,Comprehensive Cancer Center, Central Nervous System Tumours Unit (CCC-CNS), Medical University Vienna, Spitalgasse 23, BT86/E 01, Vienna, 1090, Austria
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Osaki T, Gonda K, Murahata Y, Sunden Y, Amaha T, Kunisue N, Takahashi K, Ishizuka M, Tanaka T, Li L, Yokoe I, Yamashita M, Azuma K, Tsuka T, Ito N, Imagawa T, Okamoto Y. Photodynamic detection of a feline meningioma using 5-aminolaevulinic acid hydrochloride. JFMS Open Rep 2020; 6:2055116920907429. [PMID: 32206327 PMCID: PMC7074522 DOI: 10.1177/2055116920907429] [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] [Indexed: 11/16/2022] Open
Abstract
Case summary The present study describes the case of a feline meningioma that was detected using 5-aminolaevulinic acid hydrochloride (5-ALA)-induced protoporphyrin IX (PpIX) fluorescence at surgery. An extra-axial mass in the temporoparietal region was observed by MRI. Following craniectomy and durotomy, photodynamic detection (PDD) was performed for detection of the tumour. Intratumour PpIX was detected using fluorescence spectrum evaluation and high-performance liquid chromatography. PDD revealed bright fluorescence of PpIX induced by 5-ALA, facilitating fluorescence-guided resection of the tumour tissue. Postoperative examination demonstrated an intratumour PpIX protein concentration of 16.8 nmol/g, and based on histopathological findings we diagnosed the mass as meningioma. Relevance and novel information PDD using 5-ALA has been used to identify the surgical margins during resection of primary human brain tumours. Recently, we have reported post-mortem PDD using 5-ALA for a canine glioblastoma. To our knowledge, this technique has not been previously used for the detection and resection of feline brain tumours. Our findings suggest that PDD using 5-ALA is useful for intraoperative fluorescence-guided resection of malignant meningioma in cats.
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Affiliation(s)
- Tomohiro Osaki
- Joint Department of Veterinary Medicine, Faculty of Agriculture, Tottori University, Tottori, Japan
| | - Kengo Gonda
- Joint Department of Veterinary Medicine, Faculty of Agriculture, Tottori University, Tottori, Japan
| | - Yusuke Murahata
- Joint Department of Veterinary Medicine, Faculty of Agriculture, Tottori University, Tottori, Japan
| | - Yuji Sunden
- Joint Department of Veterinary Medicine, Faculty of Agriculture, Tottori University, Tottori, Japan
| | - Takao Amaha
- Joint Department of Veterinary Medicine, Faculty of Agriculture, Tottori University, Tottori, Japan
| | | | | | | | | | - Liming Li
- Department of Bio- and Material Photonics, Chitose Institute of Science and Technology, Chitose, Hokkaido, Japan
| | - Inoru Yokoe
- Joint Department of Veterinary Medicine, Faculty of Agriculture, Tottori University, Tottori, Japan
| | - Masamichi Yamashita
- Joint Department of Veterinary Medicine, Faculty of Agriculture, Tottori University, Tottori, Japan
| | - Kazuo Azuma
- Joint Department of Veterinary Medicine, Faculty of Agriculture, Tottori University, Tottori, Japan
| | - Takeshi Tsuka
- Joint Department of Veterinary Medicine, Faculty of Agriculture, Tottori University, Tottori, Japan
| | - Norihiko Ito
- Joint Department of Veterinary Medicine, Faculty of Agriculture, Tottori University, Tottori, Japan
| | - Tomohiro Imagawa
- Joint Department of Veterinary Medicine, Faculty of Agriculture, Tottori University, Tottori, Japan
| | - Yoshiharu Okamoto
- Joint Department of Veterinary Medicine, Faculty of Agriculture, Tottori University, Tottori, Japan
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Fluorescence-guided resection in bone and soft tissue infiltrating meningiomas. Acta Neurochir (Wien) 2020; 162:605-611. [PMID: 31873793 DOI: 10.1007/s00701-019-04179-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2019] [Accepted: 12/12/2019] [Indexed: 10/25/2022]
Abstract
BACKGROUND Bone infiltration of the tumour is common in meningioma surgery. This may also affect patients without indicative signs of bone infiltration on preoperative imaging. Unrecognized bone invasion may lead to higher recurrence rates. 5-ALA fluorescence-guided resection (5-ALA-fg) could be a promising tool to help recognize possible bone invasion and/or tumour remnants. However, there is still little data about 5-ALA-fg resection in bone and soft tissue infiltrating meningiomas. METHODS We performed a retrospective study of 11 patients who were operated with the aid of 5-ALA due to bone and soft tissue infiltrating meningiomas at the University Hospital of St. Poelten between 2013 and 2019. RESULTS Strong and homogeneous fluorescence of the meningioma was observed in 9 cases (81.8%) and vague and heterogeneous fluorescence in 2 cases (18.2%). Hyperostosis on computerized tomography was evident in 3 of 6 cases (50%) and bone infiltration was visible in preoperative magnetic resonance imaging in 7 of 11 patients (63.6%). All eleven patients showed positive fluorescence of the bone infiltrating part. In all 7 cases where tissue could be collected, histopathological testing verified tumour infiltration (100%). There was also fluorescence of the periosteum in 3 cases and histopathological testing verified tumour infiltration in 100%. CONCLUSION There is growing evidence that 5-ALA-fg resection can help to identify bone infiltration in meningioma surgery. Therefore, it may help to improve extent of resection. However, further studies are necessary to investigate the rate of false-negative fluorescence and its effect on progression free survival. If 5-ALA-fg resection of meningioma is performed, the attending surgeon should also consider investigating the adjacent periosteum under blue light for detection of possible fluorescence.
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Shimanskiy VN, Karnaukhov VV, Galkin MV, Tanyashin SV, Golanov AV, Poshataev VK, Shevchenko KV. [Treatment of petroclival meningiomas: current state of the problem]. ZHURNAL VOPROSY NEĬROKHIRURGII IMENI N. N. BURDENKO 2020; 83:78-89. [PMID: 32031171 DOI: 10.17116/neiro20198306178] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Petroclival meningiomas (PCMs) are benign, slowly growing tumors. Surgery still remains the main treatment option for them. The desire for total resection of large extended PCMs often leads to the development or worsening of persistent neurological deficits. This paper presents a review of the world literature devoted to petroclival meningiomas. We discuss the issues of PCM classification, biology, diagnosis, and selection of the optimal algorithm for their treatment.
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Affiliation(s)
| | | | - M V Galkin
- Burdenko Neurosurgical Center, Moscow, Russia
| | | | - A V Golanov
- Burdenko Neurosurgical Center, Moscow, Russia
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Navarro-Bonnet J, Suarez-Meade P, Brown DA, Chaichana KL, Quinones-Hinojosa A. Following the light in glioma surgery: a comparison of sodium fluorescein and 5-aminolevulinic acid as surgical adjuncts in glioma resection. J Neurosurg Sci 2020; 63:633-647. [PMID: 31961116 DOI: 10.23736/s0390-5616.19.04745-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Gliomas are molecularly complex neoplasms and require a multidisciplinary approach to treatment. Maximal safe resection is often the initial goal of treatment and extent of resection (EOR) is an important prognostic factor correlating with both progression-free-survival (PFS) and overall survival (OS). Postoperative patient outcome is also a critical and independent prognosticator and high EOR must not be achieved at the expense of good functional outcome. Several intraoperative adjuvant techniques have been developed to help the surgeon push the boundaries of EOR while maintaining safety. Fluorescence-guided surgery for brain tumors is a contemporary adjuvant technique that allows for intraoperative delineation of diseased and normal brain thus improving maximal safe resection. The most extensively used fluorophores are 5-aminolevulinic acid (5-ALA) and sodium fluorescein (SFL). These fluorophores have different spectrophotometric properties, mechanisms of action and considerations for use. Both have demonstrated utility in neurosurgical oncology. They are safe and both are FDA approved for use as surgical adjuncts during resection of primary CNS neoplasms although they have been used with varying success for other tumor types. When combined with other surgical adjuvant strategies such as neuronavigation, intraoperative ultrasound, intraoperative MRI, awake resection and/or electrophysiological mapping/monitoring, fluorescence-guided resection appears to further improve resection quality in regard to EOR and safety. In this article, we review the current knowledge related to both fluorophores for brain tumor resection, their benefits, and pitfalls, as well as the major advantages associated with their use. We also briefly review additional fluorophores in early clinical development. Fluorescence-guided surgery is a novel surgical adjuvant which allows for real-time delineation of neoplastic tissues. The most widely used fluorophores are 5-ALA and SFL. They are safe compounds and there is a large body of evidence suggesting improvement in EOR when these are employed. There are nuances to the use of each; the fluorescence intensity is dose-dependent in either case and the sensitivity and specificity for various tumors vary widely. Additional prospective studies will be necessary to parse the impact of this technique and these fluorophores on survival metrics.
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Affiliation(s)
- Jorge Navarro-Bonnet
- Department of Neurosurgery, Medica Sur Clinical Foundation, Mexico City, Mexico - .,Faculty of Health Sciences, Anahuac University, Mexico City, Mexico -
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Dijkstra BM, Jeltema HRJR, Kruijff S, Groen RJM. The application of fluorescence techniques in meningioma surgery-a review. Neurosurg Rev 2019; 42:799-809. [PMID: 30519770 PMCID: PMC6821664 DOI: 10.1007/s10143-018-01062-4] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2018] [Revised: 11/11/2018] [Accepted: 11/23/2018] [Indexed: 12/27/2022]
Abstract
Surgical resections of meningiomas, the most common intracranial tumor in adults, can only be curative if radical resection is achieved. Potentially, the extent of resection could be improved, especially in complex and/or high-grade meningiomas by fluorescence-guided surgery using 5-aminolevulinic acid (5-ALA), indocyanine green (ICG), or fluorescein. This review aims to summarize and evaluate these fluorescence-guided meningioma surgery techniques. PubMed and Embase were searched for relevant articles. Additionally, we checked reference lists for further studies. Forty-eight articles were included in the final analysis. 5-ALA fluoresced with varying sensitivity and selectivity in meningiomas and in invaded bone and dura mater. Although ICG was mainly applied for video angiography, one report shows tumor fluorescence 18-28 h post-ICG injection. Lastly, the use of fluorescein could aid in the identification of tumor remnants; however, detection of dural tail is highly questionable. Fluorescence-guided meningioma surgery should be a reliable, highly specific, and sensitive technique. Despite numerous studies reporting the use of fluorescent dyes, currently, there is no evidence that these tools improve the radical resection rate and long-term recurrence-free outcome in meningioma surgery without neurological deficits. Evidence regarding the effectiveness and increased safety of resection after the application of these fluorophores is currently lacking. Future research should focus on the development of a meningioma-targeted, highly sensitive, and specific fluorophore.
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Affiliation(s)
- Bianca M Dijkstra
- Department of Neurosurgery, University Medical Center Groningen, University of Groningen, Hanzeplein 1, P.O. Box 30.001, 9700 RB, Groningen, The Netherlands
| | - Hanne-Rinck J R Jeltema
- Department of Neurosurgery, University Medical Center Groningen, University of Groningen, Hanzeplein 1, P.O. Box 30.001, 9700 RB, Groningen, The Netherlands
| | - Schelto Kruijff
- Department of Surgery, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Rob J M Groen
- Department of Neurosurgery, University Medical Center Groningen, University of Groningen, Hanzeplein 1, P.O. Box 30.001, 9700 RB, Groningen, The Netherlands.
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Goryaynov SA, Okhlopkov VA, Golbin DA, Chernyshov KA, Svistov DV, Martynov BV, Kim AV, Byvaltsev VA, Pavlova GV, Batalov A, Konovalov NA, Zelenkov PV, Loschenov VB, Potapov AA. Fluorescence Diagnosis in Neurooncology: Retrospective Analysis of 653 Cases. Front Oncol 2019; 9:830. [PMID: 31552168 PMCID: PMC6747044 DOI: 10.3389/fonc.2019.00830] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2019] [Accepted: 08/13/2019] [Indexed: 12/14/2022] Open
Abstract
Objective: This study is to analyze fluorescence sensitivity in the diagnosis of brain and spinal cord tumors. Material and methods: The authors conducted a multicenter retrospective analysis of data on 653 cases in 641 patients: 553 of them had brain tumors and 88 spinal cord tumors. Brain tumor resection was performed in 523 patients, of whom 484 were adults and 39 children. The analyzed series was presented by 320 gliomas, 101 meningiomas, and 72 metastases. A stereotactic biopsy was performed in 20 patients and endoscopic surgery in 10 patients. In all cases, 20 mg/kg of 5-Aminolaevulinic acid was administered orally 2-h before surgery. All surgical interventions were performed with a microscope BLUE 400 to visualize fluorescence, while endoscopic surgery-with an endoscope equipped with a fluorescent module. Fluorescence spectroscopy was conducted in 20 cases of stereotactic biopsies and in 88 cases of spinal cord tumors. Results: Among adult brain tumors operated by microsurgical techniques, meningiomas showed the highest 5-ALA fluorescence sensitivity 94% (n = 95/101), brain metastases 84.7% (n = 61/72), low-grade gliomas 46.4% (n = 26/56), and high-grade gliomas 90.2% (n = 238/264). In children the highest 5-ALA visible fluorescence was observed in anaplastic astrocytomas 100% (n = 4/4) and in anaplastic ependymomas 100% (n = 4/4); in low-grade gliomas it made up 31.8% (n = 7/22). As for the spinal cord tumors in adults, the highest sensitivity was demonstrated by glioblastomas 100% (n = 4/4) and by meningiomas 100% (n = 4/4); Fluorescence was not found in gemangioblastomas (n = 0/6) and neurinomas (n = 0/4). Fluorescence intensity reached 60% (n = 6/10) in endoscopic surgery and 90% (n = 18/20) in stereotactic biopsy. Conclusion: 5-ALA fluorescence diagnosis proved to be most sensitive in surgery of HGG and meningioma (90.2 and 94.1%, respectively). Sensitivity in surgery of intracranial metastases and spinal cord tumors was slightly lower (84.7 and 63.6%, correspondingly). The lowest fluorescence sensitivity was marked in pediatric tumors and LGG (50 and 46.4%, correspondingly). Fluorescence diagnosis can also be used in transnasal endoscopic surgery of skull base tumors and in stereotactic biopsy.
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Affiliation(s)
- Sergey A. Goryaynov
- N. N. Burdenko National Medical Research Center of Neurosurgery of the Ministry of Health of the Russian Federation, Moscow, Russia
| | - Vladimir A. Okhlopkov
- N. N. Burdenko National Medical Research Center of Neurosurgery of the Ministry of Health of the Russian Federation, Moscow, Russia
| | - Denis A. Golbin
- N. N. Burdenko National Medical Research Center of Neurosurgery of the Ministry of Health of the Russian Federation, Moscow, Russia
| | - Konstantin A. Chernyshov
- I. M. Sechenov First Moscow State Medical University of the Ministry of Health of the Russian Federation, Moscow, Russia
| | - Dmitrij V. Svistov
- S. M. Kirov Military Medical Academy of the Ministry of Defense of the Russian Federation, St-Petersburg, Russia
| | - Boris V. Martynov
- S. M. Kirov Military Medical Academy of the Ministry of Defense of the Russian Federation, St-Petersburg, Russia
| | - Alexandr V. Kim
- V. A. Almazov Federal North-West Medical Research Centre of the Ministry of Health of the Russian Federation, St-Petersburg, Russia
| | - Vadim A. Byvaltsev
- Laboratory of Neurosurgery, Irkutsk Scientific Center of Surgery and Traumatology, Irkutsk, Russia
- Department of Neurosurgery, Irkutsk State Medical University, Irkutsk, Russia
| | - Galina V. Pavlova
- Institute of Gene Biology, Russian Academy of Science, Moscow, Russia
| | - Artem Batalov
- N. N. Burdenko National Medical Research Center of Neurosurgery of the Ministry of Health of the Russian Federation, Moscow, Russia
| | - Nikolay A. Konovalov
- N. N. Burdenko National Medical Research Center of Neurosurgery of the Ministry of Health of the Russian Federation, Moscow, Russia
| | - Petr V. Zelenkov
- N. N. Burdenko National Medical Research Center of Neurosurgery of the Ministry of Health of the Russian Federation, Moscow, Russia
| | - Victor B. Loschenov
- Prokhorov General Physics Institute of the Russian Academy of Science, Moscow, Russia
- National Research Nuclear University MEPhI, Moscow, Russia
| | - Alexandr A. Potapov
- N. N. Burdenko National Medical Research Center of Neurosurgery of the Ministry of Health of the Russian Federation, Moscow, Russia
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Knipps J, Fischer I, Neumann LM, Rapp M, Dibué-Adjei M, Freiin von Saß C, Placke JM, Mijderwijk HJ, Steiger HJ, Sabel M, Cornelius JF, Kamp MA. Quantification of PpIX-fluorescence of cerebral metastases: a pilot study. Clin Exp Metastasis 2019; 36:467-475. [PMID: 31376098 DOI: 10.1007/s10585-019-09986-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2019] [Accepted: 07/29/2019] [Indexed: 12/25/2022]
Abstract
5-ALA fluorescence-guided surgery (FGS) is a major advance in neuro-oncological surgery. So far, Protoporphyrin IX (PpIX)-fluorescence has been observed in about half of cerebral metastases resected with routinely equipped microscopes during 5-ALA FGS. The aim of the present pilot study was to quantify PpIX-induced fluorescence of cerebral metastases with a spectrometer. We hypothesize that non-fluorescing metastases under the operating microscope may have spectrometrically measurable levels of fluorescence. A second aim was to analyze correlations between quantified 5-ALA fluorescence and histology or primary tumor type, respectively. Standard FGS was performed in all patients. The fluorescence intensity of the metastasis was semi-quantitatively determined in vivo by a senior surgeon using a special surgical microscope equipped for FGS. A systematic spectrometric ex vivo evaluation of tumor specimens and PpIX-induced fluorescence was performed using a spectrometer connected by optic fibers to a handheld probe. Quantification of 5-ALA-derived fluorescence was measured in a standardized manner with direct contact between mini-spectrometer and metastasis. The difference between the maximum PpIX-fluorescence at 635 nm and the baseline fluorescence was defined as the PpIX fluorescence intensity of the metastasis and given in arbitrary units (AU). Diagnosis of a cerebral metastasis was confirmed by histopathological analysis. A total of 29 patients with cerebral metastases were included. According to neuropathological analysis, 11 patients suffered from non-small cell lung cancer, 10 patients from breast cancer, 6 patients from cancer originating in the gastro-intestinal tract, 1 patient suffered from a malignant melanoma and one patient from renal cancer. The mean age was 63 years (37-81 years). 15 patients were female, 14 patients male. 13 cerebral metastases were considered as ALA-positive by the surgeon. In nine metastases, 5-ALA fluorescence was not visible to the naked eye and could only be detected using the spectrometer. The threshold for an ALA signal rated as "positive" by the surgeon was PpIX fluorescence above 1.1 × 106 AU. The mean PpIX fluorescence of all analyzed cerebral metastases was 1.29 × 106 ± 0.23 × 106 AU. After quantification, we observed a significant difference between the mean 5-ALA-derived fluorescence in NSCLC and breast cancer metastases (Mean Diff: - 1.2 × 106; 95% CI of difference: - 2.2 × 106 to - 0.15 × 106; Šidák-adjusted p = 0.026). In our present pilot series, about half of cerebral metastases showed a 5-ALA fluorescence invisible to the naked eye. Over 50% of these non-fluorescent metastases show a residual 5-ALA fluorescence which can be detected and quantified using a spectrometer. Moreover, the quantified 5-ALA signal significantly differed with respect to the primary tumor of the corresponding cerebral metastasis. Further studies should evaluate the predictive value of the 5-ALA signal and if a quantified 5-ALA signal enables a reliable intraoperative differentiation between residual tumor tissue and edematous brain-in particular in metastases with a residual fluorescence signal invisible to the naked eye.
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Affiliation(s)
- Johannes Knipps
- Department of Neurosurgery, Medical Faculty, Heinrich-Heine-University, Düsseldorf, Moorenstraße 5, 40225, Düsseldorf, Germany.
| | - Igor Fischer
- Division of Informatics and Statistics, Department of Neurosurgery, Medical Faculty, Heinrich-Heine-University, Düsseldorf, Moorenstraße 5, 40225, Düsseldorf, Germany
| | - Lisa M Neumann
- Department of Neurosurgery, Medical Faculty, Heinrich-Heine-University, Düsseldorf, Moorenstraße 5, 40225, Düsseldorf, Germany
| | - Marion Rapp
- Department of Neurosurgery, Medical Faculty, Heinrich-Heine-University, Düsseldorf, Moorenstraße 5, 40225, Düsseldorf, Germany
| | - Maxine Dibué-Adjei
- Department of Neurosurgery, Medical Faculty, Heinrich-Heine-University, Düsseldorf, Moorenstraße 5, 40225, Düsseldorf, Germany
| | - Christiane Freiin von Saß
- Department of Neurosurgery, Medical Faculty, Heinrich-Heine-University, Düsseldorf, Moorenstraße 5, 40225, Düsseldorf, Germany
| | - Jan-Malte Placke
- Department of Neurosurgery, Medical Faculty, Heinrich-Heine-University, Düsseldorf, Moorenstraße 5, 40225, Düsseldorf, Germany
| | - Hendrik-Jan Mijderwijk
- Department of Neurosurgery, Medical Faculty, Heinrich-Heine-University, Düsseldorf, Moorenstraße 5, 40225, Düsseldorf, Germany.,Division of Informatics and Statistics, Department of Neurosurgery, Medical Faculty, Heinrich-Heine-University, Düsseldorf, Moorenstraße 5, 40225, Düsseldorf, Germany
| | - Hans-Jakob Steiger
- Department of Neurosurgery, Medical Faculty, Heinrich-Heine-University, Düsseldorf, Moorenstraße 5, 40225, Düsseldorf, Germany
| | - Michael Sabel
- Department of Neurosurgery, Medical Faculty, Heinrich-Heine-University, Düsseldorf, Moorenstraße 5, 40225, Düsseldorf, Germany
| | - Jan-Frederick Cornelius
- Department of Neurosurgery, Medical Faculty, Heinrich-Heine-University, Düsseldorf, Moorenstraße 5, 40225, Düsseldorf, Germany
| | - Marcel A Kamp
- Department of Neurosurgery, Medical Faculty, Heinrich-Heine-University, Düsseldorf, Moorenstraße 5, 40225, Düsseldorf, Germany
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Management of pediatric CNS meningiomas: CCHE-57357 experience in 39 cases. Childs Nerv Syst 2019; 35:1323-1331. [PMID: 31127346 DOI: 10.1007/s00381-019-04156-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2018] [Accepted: 04/14/2019] [Indexed: 10/26/2022]
Abstract
PURPOSE Our aim is to present our experience in the management of pediatric meningiomas in the largest referral center in Egypt for pediatric tumors focusing on variables including clinical picture, anatomic location, histopathology, treatment strategies, and outcome together with their possible correlation to prognosis. METHODS We retrospectively reviewed the medical records of 39 pediatric patients who were treated for CNS meningiomas in Children's Cancer Hospital-Egypt (CCHE-57357) 2007-2017. RESULTS The prevalence of pediatric meningioma was 1.42%. Four cases had type 2 neurofibromatosis (NFII). The mean age was 8.19 years. The presence of NFII was associated with challenging multiple lesions, older age of presentation and poorer prognosis and functional outcome. Convexity was the commonest location. Gross total resection (GTR) was achieved in 28 cases, subtotal resection (STR) in 8 cases, and biopsy was decided in 3 patients. Histopathological examination revealed WHO grade I in 16 patients and higher grades in 23 patients (59%). The 5-year overall survival (OS) rate was 87.8% while the 5-years event-free survival (EFS) rate was 85.6%. Tumor location, histopathology, and clinical presentation were not statistically correlated to prognosis. CONCLUSIONS Pediatric CNS meningiomas are uncommon pediatric tumors but of an aggressive clinical and pathological behaviors as compared to adult meningiomas. The presence of NFII is associated with a poorer prognosis and functional outcomes. Although being challenging, the maximum and safe surgical excision should be exercised even in recurrent cases in order to achieve the best outcome. Adjuvant radiotherapy provides good tumor control for inoperable residual atypical or anaplastic meningiomas.
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Boschi A, Della Puppa A. 5-ALA fluorescence on tumors different from malignant gliomas. Review of the literature and our experience. J Neurosurg Sci 2019; 63:661-669. [PMID: 31355622 DOI: 10.23736/s0390-5616.19.04766-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
INTRODUCTION Fluorescence guided surgery with 5-aminolevulinic acid (5-ALA) is a well-established technique for improving resection of malignant cerebral glioma. In recent years, this technique is being increasingly applied off label to other brain tumor entities such as Low-grade glioma, meningioma, metastases, lymphoma and other central nervous system tumors. In this paper We collected all the data of 5-ALA guided surgery in "not malignant glioma" in literature compared to our experience. EVIDENCE ACQUISITION We searched the PubMed/Medline database all clinical series reporting 5-ALA guided-surgery in not malignant glioma. We reviewed all data also showing our experience. EVIDENCE SYNTHESIS Fluorescence guided surgery with 5-ALA might be helpful not only in high-grade glioma but also in other brain tumor especially in Low grade glioma with a suspect of anaplastic spot, meningioma with bone invasion or parenchymal infiltration, ependymoma, lymphoma and pediatric tumors. CONCLUSIONS Due to the relatively few number or clinical studies, prospective clinical trials are needed to increase the overall level of evidence concerning the usage of 5-ALA in CNS tumors different from high-grade glioma. Furthermore, a greater us of new tools such as, spectroscopy or confocal microscope or the use of combination of other fluorescence could make more effective this technique.
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Affiliation(s)
- Andrea Boschi
- Department of Neurosurgery, Careggi Hospital, University of Florence, Florence, Italy
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Rustemi O, Della Puppa A. Hyperostosis and osteolysis in skull base meningiomas: are different nuances of 5-ALA fluorescence related to different invasion patterns? J Neurosurg Sci 2019; 63:484-485. [PMID: 31210042 DOI: 10.23736/s0390-5616.17.04244-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Affiliation(s)
- Oriela Rustemi
- Department of Neurosurgery, Padua University Hospital, Padua, Italy -
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Potapov AA, Goryaynov SA, Danilov GV, Chelushkin DM, Okhlopkov VA, Shimanskiy VN, Beshplav ST, Poshataev VK, Shishkina LV, Zakharova NE, Spallone A, Savel'eva TA, Loshchenov VB. [Intraoperative fluorescence diagnostics in surgery of intracranial meningiomas: analysis of 101 cases]. ZHURNAL VOPROSY NEĬROKHIRURGII IMENI N. N. BURDENKO 2019; 82:17-29. [PMID: 29795083 DOI: 10.17116/oftalma201882217-29] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Fluorescence diagnostics has been extensively applied in surgery of malignant brain gliomas. However, the use of this technique in surgery of intracranial meningiomas has remained controversial. OBJECTIVE The study objective was to assess the sensitivity of 5-aminolevulinic acid-based (5-ALA) fluorescence diagnostics in surgery of brain meningiomas and to clarify the clinical and biological factors that may influence the fluorescent effect. MATERIAL AND METHODS The study consistently included 101 patients with intracranial meningiomas of various locations who were operated on using 5-ALA. There were 28 (27.72%) males and 73 (72.27%) females (median age, 54 years). In all patients, surgery was performed using an operating microscope equipped with a fluorescent module; in 24 of these, laser spectroscopy was used. For comparison of chances to observe the fluorescent effect of 5-ALA in patients having meningiomas with different WHO histological grades (Grade I vs Grade II-III), we performed a meta-analysis that included 10 studies (the largest series) on outcomes of surgical treatment of meningiomas using intraoperative fluorescence diagnostics. RESULTS Of 101 patients included in this series, observable fluorescence was detected in 95 (94.1%) patients: weak fluorescence in 12 (11.9%), moderate fluorescence in 23 (22.8%) cases, and strong fluorescence in 60 (59.4%) patients. There was no statistically significant relationship (p>0.05) between the rate and intensity of observable fluorescence and the tumor growth pattern (primary/continued), location, WHO grade of malignancy, and histological subtype. In the absence of intraoperative bleeding, tumor fluorescence was statistically significantly brighter (p=0.02). Of 26 patients with hyperostosis, bone fluorescence was observed in 11 (42.3%) cases. There was no statistically significant relationship between administration of dexamethasone, its dose, administration of anticonvulsants, gastrointestinal tract diseases, as well as diabetes mellitus and the fluorescence intensity. There was also no significant relationship between the extent of tumor resection (Simpson scale) and the presence of fluorescence as well as its intensity. Comparison of the observable fluorescence intensity and the laser spectroscopy indicators revealed a significant correlation (r=0.75; p=0.005). CONCLUSION Meningioma is a well fluorescent tumor, with the technique sensitivity being 94.1%. In some cases, the use of fluorescence diagnostics in surgery of meningiomas improves identification of residual tumor fragments and enables correction of a surgical approach. To assess the effect of fluorescence diagnostics on the recurrence rate and disease-free duration, further research is required.
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Affiliation(s)
- A A Potapov
- Burdenko Neurosurgical Institute, 4-ya Tverskaya-Yamskaya Str., 16, Moscow, Russia, 125047
| | - S A Goryaynov
- Burdenko Neurosurgical Institute, 4-ya Tverskaya-Yamskaya Str., 16, Moscow, Russia, 125047
| | - G V Danilov
- Burdenko Neurosurgical Institute, 4-ya Tverskaya-Yamskaya Str., 16, Moscow, Russia, 125047
| | - D M Chelushkin
- Burdenko Neurosurgical Institute, 4-ya Tverskaya-Yamskaya Str., 16, Moscow, Russia, 125047
| | - V A Okhlopkov
- Burdenko Neurosurgical Institute, 4-ya Tverskaya-Yamskaya Str., 16, Moscow, Russia, 125047
| | - V N Shimanskiy
- Burdenko Neurosurgical Institute, 4-ya Tverskaya-Yamskaya Str., 16, Moscow, Russia, 125047
| | - Sh T Beshplav
- Burdenko Neurosurgical Institute, 4-ya Tverskaya-Yamskaya Str., 16, Moscow, Russia, 125047
| | - V K Poshataev
- Burdenko Neurosurgical Institute, 4-ya Tverskaya-Yamskaya Str., 16, Moscow, Russia, 125047
| | - L V Shishkina
- Burdenko Neurosurgical Institute, 4-ya Tverskaya-Yamskaya Str., 16, Moscow, Russia, 125047
| | - N E Zakharova
- Burdenko Neurosurgical Institute, 4-ya Tverskaya-Yamskaya Str., 16, Moscow, Russia, 125047
| | - A Spallone
- Department of Biomedicine, University of Rome Tor Vergata and NCL-Institute of Neurological Sciences, Rome, Italy; Neurological Center of Latium, Via Patrica 15, Rome, 00178, Italy
| | - T A Savel'eva
- Prokhorov General Physics Institute. Vavilova Str., 38, Moscow, Russia, 119991; National Research Nuclear University MEPhI, Kashirskoe Shosse, 31, Moscow, Russia, 115409
| | - V B Loshchenov
- Prokhorov General Physics Institute. Vavilova Str., 38, Moscow, Russia, 119991; National Research Nuclear University MEPhI, Kashirskoe Shosse, 31, Moscow, Russia, 115409
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Picart T, Berhouma M, Dumot C, Pallud J, Metellus P, Armoiry X, Guyotat J. Optimization of high-grade glioma resection using 5-ALA fluorescence-guided surgery: A literature review and practical recommendations from the neuro-oncology club of the French society of neurosurgery. Neurochirurgie 2019; 65:164-177. [PMID: 31125558 DOI: 10.1016/j.neuchi.2019.04.005] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2019] [Revised: 04/17/2019] [Accepted: 04/28/2019] [Indexed: 11/20/2022]
Abstract
BACKGROUND When feasible, the surgical resection is the standard first step of the management of high-grade gliomas. 5-ALA fluorescence-guided-surgery (5-ALA-FGS) was developed to ease the intra-operative delineation of tumor borders in order to maximize the extent of resection. METHODS A Medline electronic database search was conducted. English language studies from January 1998 until July 2018 were included, following the PRISMA guidelines. RESULTS 5-ALA can be considered as a specific tool for the detection of tumor remnant but has a weaker sensibility (level 2). 5-ALA-FGS is associated with a significant increase in the rate of gross total resection reaching more than 90% in some series (level 1). Consistently, 5-ALAFGS improves progression-free survival (level 1). However, the gain in overall survival is more debated. The use of 5-ALA-FGS in eloquent areas is feasible but requires simultaneous intraoperative electrophysiologic functional brain monitoring to precisely locate and preserve eloquent areas (level 2). 5-ALA is usable during the first resection of a glioma but also at recurrence (level 2). From a practical standpoint, 5-ALA is orally administered 3 hours before the induction of anesthesia, the recommended dose being 20 mg/kg. Intra-operatively, the procedure is performed as usually with a central debulking and a peripheral dissection during which the surgeon switches from white to blue light. Provided that some precautions are observed, the technique does not expose the patient to particular complications. CONCLUSION Although 5-ALA-FGS contributes to improve gliomas management, there are still some limitations. Future methods will be developed to improve the sensibility of 5-ALA-FGS.
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Affiliation(s)
- T Picart
- Service de neurochirurgie D, hospices civils de Lyon, hôpital neurologique Pierre-Wertheimer, 59, boulevard Pinel, 69677 Bron, France; Inserm 1052, UMR 5286,Team ATIP/AVENIR Transcriptomic diversity of stem cells, centre de cancérologie de Lyon, centre Léon-Bérard, 69008 Lyon, France.
| | - M Berhouma
- Service de neurochirurgie D, hospices civils de Lyon, hôpital neurologique Pierre-Wertheimer, 59, boulevard Pinel, 69677 Bron, France; CREATIS Laboratory, Inserm U1206, UMR 5220, université de Lyon, 69100 Villeurbanne, France
| | - C Dumot
- Service de neurochirurgie D, hospices civils de Lyon, hôpital neurologique Pierre-Wertheimer, 59, boulevard Pinel, 69677 Bron, France; CREATIS Laboratory, Inserm U1206, UMR 5220, université de Lyon, 69100 Villeurbanne, France
| | - J Pallud
- Département de neurochirurgie, hôpital Sainte-Anne, 75014 Paris, France; Université Paris Descartes, Sorbonne Paris Cité, 75005 Paris, France; IMA-Brain, Inserm U894, institut de psychiatrie et neurosciences de Paris, 7013 Paris, France
| | - P Metellus
- Hôpital Privé Clairval, Ramsay général de santé, 13009 Marseille, France; UMR 7051, institut de neurophysiopathologie, université d'Aix-Marseille, 13344 Marseille, France
| | - X Armoiry
- MATEIS (Team I2B), University of Lyon, Lyon school of pharmacy, 69008 Lyon, France; Édouard-Herriot Hospital, Pharmacy Department, 69008 Lyon, France; University of Warwick, Warwick Medical School, Coventry, UK
| | - J Guyotat
- Service de neurochirurgie D, hospices civils de Lyon, hôpital neurologique Pierre-Wertheimer, 59, boulevard Pinel, 69677 Bron, France
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Linsler S, Ketter R, Oertel J, Urbschat S. Fluorescence imaging of meningioma cells with somatostatin receptor ligands: an in vitro study. Acta Neurochir (Wien) 2019; 161:1017-1024. [PMID: 30877475 DOI: 10.1007/s00701-019-03872-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2018] [Accepted: 03/06/2019] [Indexed: 10/27/2022]
Abstract
BACKGROUND The use of five-aminolevulinic acid (5-ALA) in the staining of malignant glioma cells has significantly improved intraoperative radicality in the resection of gliomas in the last decade. Currently, there is no comparable selective fluorescent substance available for meningiomas. There is however a demand for intraoperative fluorescent identification of, e.g., invasive skull base meningiomas to help improve safe radical resection. Meningiomas show high expression of the somatostatin receptor type 2, offering the possibility of receptor-targeted imaging. The authors used a somatostatin receptor-labeled fluorescence dye in the identification of meningiomas in vitro. The aim of this study was to evaluate the possibility of selective identification of meningioma cells with fluorescent techniques. METHODS Twenty-four primary human meningioma cell cultures were analyzed. The tumor cells were incubated with FAM-TOC (5,6-Carboxyfluoresceine-Tyr3-Octreotide). As a negative control, four human dura tissues were cultured as well as a mixed cell culture in vitro and incubated with the same somatostatin receptor-labeled fluorescence substance. After incubation, fluorescence signal and intensity in all cell cultures were analyzed at three different time points using a fluorescence microscope with 488 nm epi-illumination. RESULTS Sixteen WHO I, six WHO II, two WHO III meningioma primary cell cultures, and four dura cell cultures were analyzed. Fluorescence was detected in all meningioma cell cultures (22 cell culture stained strongly, 2 cell cultures moderately) directly after incubation up until 4 h later. There were no differences in the quality and quantity of fluorescence signal between the various meningioma grades. The fluorescence signal persisted unchanged during the analyzed period. In the negative control, dura cell cultures remained unstained. CONCLUSIONS This study demonstrates the use of FAM-TOC in the selective fluorescent identification of meningioma cells in vitro. Further evaluation of the chemical kinetics of the applied somatostatin receptor ligand and fluorescence dye is warranted. As a next step, an experimental animal model is needed to evaluate these promising results in vivo.
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Omoto K, Matsuda R, Nakai Y, Tatsumi Y, Nakazawa T, Tanaka Y, Shida Y, Murakami T, Nishimura F, Nakagawa I, Motoyama Y, Nakamura M, Fujimoto K, Hiroyuki N. Expression of peptide transporter 1 has a positive correlation in protoporphyrin IX accumulation induced by 5-aminolevulinic acid with photodynamic detection of non-small cell lung cancer and metastatic brain tumor specimens originating from non-small cell lung cancer. Photodiagnosis Photodyn Ther 2019; 25:309-316. [PMID: 30639584 DOI: 10.1016/j.pdpdt.2019.01.009] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2018] [Revised: 12/11/2018] [Accepted: 01/07/2019] [Indexed: 12/11/2022]
Abstract
BACKGROUND Recently, 5-aminolevulinic acid (5-ALA)-induced protoporphyrin IX fluorescence was reported to be a useful tool during total surgical resection of high-grade gliomas. However, the labeling efficacy of protoporphyrin IX fluorescence is lower in metastatic brain tumors compared to that in high-grade gliomas, and the mechanism underlying protoporphyrin IX fluorescence in metastatic brain tumors remains unclear. Lung cancer, particularly non-small cell lung cancer (NSCLC), is the most common origin for metastatic brain tumor. Therefore, we investigated the mechanism of protoporphyrin IX fluorescence in NSCLC and associated metastatic brain tumors. METHODS Western blotting and quantitative real-time polymerase chain reaction (qRT-PCR) was employed to evaluate the protein and mRNA levels of five transporters and enzymes involved in the porphyrin biosynthesis pathway: peptide transporter 1 (PEPT1), hydroxymethylbilane synthase (HMBS), ferrochelatase (FECH), ATP-binding cassette 2 (ABCG2), and heme oxygenase 1 (HO-1). The correlation between protein, mRNA, and protoporphyrin IX levels in NSCLC cells were evaluated in vitro. Immunohistochemistry was used to determine proteins that played a key role in intraoperative protoporphyrin IX fluorescence in clinical samples from patients with NSCLC and pathologically confirmed metastatic brain tumors. RESULTS A significant correlation between PEPT1 expression and protoporphyrin IX accumulation in vitro was identified by western blotting (P = 0.003) and qRT-PCR (P = 0.04). Immunohistochemistry results indicated that there was a significant difference in PEPT1 between the intraoperative protoporphyrin IX fluorescence-positive and protoporphyrin IX fluorescence-negative groups (P = 0.009). CONCLUSION Expression of PEPT1 was found to be positively correlated with 5-ALA-induced protoporphyrin IX accumulation detected by photodynamic reaction in metastatic brain tumors originating from NSCLC.
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Affiliation(s)
- Koji Omoto
- Department of Neurosurgery, Nara Medical University, Kashihara, Nara, Japan
| | - Ryosuke Matsuda
- Department of Neurosurgery, Nara Medical University, Kashihara, Nara, Japan.
| | - Yasushi Nakai
- Department of Urology, Nara Medical University, Kashihara, Nara, Japan
| | - Yoshihiro Tatsumi
- Department of Urology, Nara Medical University, Kashihara, Nara, Japan
| | - Tsutomu Nakazawa
- Department of Neurosurgery, Nara Medical University, Kashihara, Nara, Japan; Grandsoul Research Institute for Immunology, Inc., Uda, Nara, Japan
| | - Yoshitaka Tanaka
- Department of Neurosurgery, Nara Medical University, Kashihara, Nara, Japan
| | - Yoichi Shida
- Department of Neurosurgery, Nara Medical University, Kashihara, Nara, Japan
| | - Toshiharu Murakami
- Department of Neurosurgery, Nara Medical University, Kashihara, Nara, Japan
| | - Fumihiko Nishimura
- Department of Neurosurgery, Nara Medical University, Kashihara, Nara, Japan
| | - Ichiro Nakagawa
- Department of Neurosurgery, Nara Medical University, Kashihara, Nara, Japan
| | - Yasushi Motoyama
- Department of Neurosurgery, Nara Medical University, Kashihara, Nara, Japan
| | | | - Kiyohide Fujimoto
- Department of Urology, Nara Medical University, Kashihara, Nara, Japan
| | - Nakase Hiroyuki
- Department of Neurosurgery, Nara Medical University, Kashihara, Nara, Japan
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Díez Valle R, Hadjipanayis CG, Stummer W. Established and emerging uses of 5-ALA in the brain: an overview. J Neurooncol 2019; 141:487-494. [PMID: 30607705 DOI: 10.1007/s11060-018-03087-7] [Citation(s) in RCA: 49] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2018] [Accepted: 12/27/2018] [Indexed: 01/08/2023]
Abstract
INTRODUCTION 5-aminolevulinic acid (5-ALA) was approved by the FDA in June 2017 as an intra-operative optical imaging agent for patients with gliomas (suspected World Health Organization Grades III or IV on preoperative imaging) as an adjunct for the visualization of malignant tissue during surgery. 5-ALA fluorescence-guided surgery (FGS) has been in widespread use in Europe and other continents since 2007. METHODS We reviewed the data available and summarize the most important known uses of 5-ALA FGS and its potential future applications. RESULTS/CONCLUSIONS The technique has been extensively studied, and more than 300 papers have been published on this topic. Visualization of high-grade glioma tissue is robust and reproducible, and can impact the extent of tumor resection and patient outcomes. 5-ALA FGS for other kind of tumors needs further development.
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Affiliation(s)
| | | | - Walter Stummer
- Department of Neurosurgery, Universitätsklinikum Münster, Münster, Germany
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5-aminolevulinic acid induced protoporphyrin IX (ALA-PpIX) fluorescence guidance in meningioma surgery. J Neurooncol 2019; 141:555-565. [PMID: 30604395 DOI: 10.1007/s11060-018-03079-7] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2018] [Accepted: 12/12/2018] [Indexed: 10/27/2022]
Abstract
INTRODUCTION 5-aminolevulinic acid induced protoporphyrin IX (5-ALA-PpIX) fluorescence guidance has emerged as a valuable surgical adjunct for resection of intracranial tumors. METHODS Here we present a focused review on 5-ALA-PpIX fluorescence guidance for meningiomas. RESULTS We discuss the clinical studies and specific applications to date as well as the two main intraoperative fluorescence technologies applied to meningiomas. CONCLUSIONS The use of 5-ALA-PpIX in meningiomas holds promising potential so neurosurgeons can improve surgical outcomes for patients with meningiomas as well as be pioneers in developing improved fluorescence imaging technologies.
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Ji SY, Kim JW, Park CK. Experience Profiling of Fluorescence-Guided Surgery II: Non-Glioma Pathologies. Brain Tumor Res Treat 2019; 7:105-111. [PMID: 31686441 PMCID: PMC6829089 DOI: 10.14791/btrt.2019.7.e39] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2019] [Revised: 07/23/2019] [Accepted: 07/30/2019] [Indexed: 01/22/2023] Open
Abstract
Background Only sporadic reports of fluorescence-guided surgery (FGS) have been published for non-glioma conditions. In this study, we focus on epidemiological data of fluorescence patterns and report the diverse experiences of FGS in non-gliomas. Methods During 8.5 years between July 2010 and January 2019, 900 FGS for brain tumor performed in Seoul National University Hospital. Among them, a total of 73 histologically proven non-glioma patients were analyzed. Indications for FGS have been the possibility of anaplastic tumor in intra-axial tumors in preoperative MRI and an attempt to reproduce known anecdotal experiences of 5-Aminolevulinic Acid (5-ALA) fluorescence. Results In cases of brain tumors except for gliomas, the most frequent cases were brain metastasis (23 cases) followed by lymphomas (9 cases) and meningeal tumors (8 cases). And there were embryonal tumors (6 cases), hemangioblastomas (4 cases), and solitary fibrous tumor/hemangiopericytomas (3 cases). Most brain metastases, meningiomas, primary central nervous system lymphomas, and treatment effect cases showed positive fluorescence. Moreover, some non-tumorous conditions also showed positive fluorescence. However, hemangioblastoma and germ cell tumor did not observe any fluorescence at all. Conclusion 5-ALA induced fluorescence is not limited to glioma but is also evident in non-glioma and non-neoplastic conditions. This 5-ALA-induced fluorescence may be used as an intraoperative tool for various brain conditions.
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Affiliation(s)
- So Young Ji
- Department of Neurosurgery, Seoul National University Hospital, Seoul, Korea
| | - Jin Wook Kim
- Department of Neurosurgery, Seoul National University Hospital, Seoul, Korea.,Department of Neurosurgery, Seoul National University College of Medicine, Seoul, Korea
| | - Chul Kee Park
- Department of Neurosurgery, Seoul National University Hospital, Seoul, Korea.,Department of Neurosurgery, Seoul National University College of Medicine, Seoul, Korea.
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The role of 5-aminolevulinic acid in spinal tumor surgery: a review. J Neurooncol 2018; 141:575-584. [PMID: 30594965 PMCID: PMC6373300 DOI: 10.1007/s11060-018-03080-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2018] [Accepted: 12/17/2018] [Indexed: 12/20/2022]
Abstract
Purpose Primary intradural spinal neoplasms account for a small proportion of central nervous system tumors. The primary treatment for these tumors consists of maximal safe resection and preservation of neurologic function. Gross total resection, which is associated with the lowest rate of tumor recurrence and longer progression-free survival for most histologies, can be difficult to achieve. Currently, the use of 5-aminolevulinc acid (5-ALA) which takes advantage of Protoporphyrin IX (PpIX) fluorescence, is a well-established technique for improving resection of malignant cerebral gliomas. This technique is being increasingly applied to other cerebral neoplasms, and multiple studies have attempted to evaluate the utility of 5-ALA-aided resection of spinal neoplasms. Methods The authors reviewed the existing literature on the use of 5-ALA and PpIX fluorescence as an aid to resection of primary and secondary spinal neoplasms by searching the PUBMED and EMBASE database for records up to March 2018. Data was abstracted from all studies describing spinal neurosurgical uses in the English language. Results In the reviewed studies, the most useful fluorescence was observed in meningiomas, ependymomas, drop metastases from cerebral gliomas, and hemangiopericytomas of the spine, which is consistent with applications in cerebral neoplasms. Conclusions The available literature is significantly limited by a lack of standardized methods for measurement and quantification of 5-ALA fluorescence. The results of the reviewed studies should guide future development of rational trial protocols for the use of 5-ALA guided resection in spinal neoplasms. Electronic supplementary material The online version of this article (10.1007/s11060-018-03080-0) contains supplementary material, which is available to authorized users.
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