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Mischkulnig M, Traxler D, Wadiura LI, Lang A, Millesi M, Kiesel B, Widhalm G. Comparison of minimal detectable protoporphyrin IX concentrations with a loupe device and conventional 5-ALA fluorescence microscopy: an experimental study. JOURNAL OF BIOMEDICAL OPTICS 2023; 28:106004. [PMID: 37915397 PMCID: PMC10617155 DOI: 10.1117/1.jbo.28.10.106004] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Revised: 09/01/2023] [Accepted: 09/01/2023] [Indexed: 11/03/2023]
Abstract
Significance The 5-aminolevulinic acid (5-ALA) fluorescence technique is now widely applied for intraoperative visualization of specific central nervous system (CNS) tumors. Previous technical implementations of this technique have relied on specifically modified surgical microscopes to visualize intratumoral fluorescent protoporphyrin (PpIX). While this approach evidently allows for reliable intraoperative tumor visualization, it requires the availability of specifically modified surgical microscopes and their use even in cases where the operating neurosurgeon would prefer to use surgical loupes. Recently, a novel loupe device was introduced that is also capable of visualizing 5-ALA fluorescence. Aim The aim of this study was therefore to compare the detected PpIX concentrations between the conventional fluorescence microscope and the novel loupe device. Approach We used fluorescence phantoms of different PpIX concentrations for comparison between a conventional fluorescence microscope and the novel loupe device. For this purpose, we created fluorescence images using the excitation light sources of the conventional fluorescence microscope and the loupe device with both available background illumination modes (low and high). Subsequently, the minimal detectable PpIX concentrations according to each technique were determined by five independent neurosurgeons. Results Using the conventional fluorescence microscope, the median minimal detectable PpIX concentration was 0.16 μ g / ml (range: 0.15 to 0.17 μ g / ml ). By the loupe device, the median minimal detectable PpIX concentration was 0.12 μ g / ml (range: 0.10 to 0.12 μ g / ml ) and 0.08 μ g / ml (range: 0.07 to 0.08 μ g / ml ) for the high- and low-modes, respectively. Altogether, the minimal detectable PpIX concentrations were significantly lower using the loupe device compared to the conventional fluorescence microscope (p = 0.007 ). Conclusions Our data indicate that the novel loupe device is able to visualize 5-ALA fluorescence with high sensitivity and thus might serve as a powerful tool for visualization of specific CNS tumors in the future.
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Affiliation(s)
- Mario Mischkulnig
- Medical University of Vienna, Department of Neurosurgery, Vienna, Austria
| | - Denise Traxler
- Medical University of Vienna, Department of Oral and Maxillofacial Surgery, Vienna, Austria
| | - Lisa I. Wadiura
- Medical University of Vienna, Department of Neurosurgery, Vienna, Austria
| | - Alexandra Lang
- Medical University of Vienna, Department of Neurosurgery, Vienna, Austria
| | - Matthias Millesi
- Medical University of Vienna, Department of Neurosurgery, Vienna, Austria
| | - Barbara Kiesel
- Medical University of Vienna, Department of Neurosurgery, Vienna, Austria
| | - Georg Widhalm
- Medical University of Vienna, Department of Neurosurgery, Vienna, Austria
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Goryaynov SA, Buklina SB, Khapov IV, Batalov AI, Potapov AA, Pronin IN, Belyaev AU, Aristov AA, Zhukov VU, Pavlova GV, Belykh E. 5-ALA-guided tumor resection during awake speech mapping in gliomas located in eloquent speech areas: Single-center experience. Front Oncol 2022; 12:940951. [PMID: 36212421 PMCID: PMC9538677 DOI: 10.3389/fonc.2022.940951] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2022] [Accepted: 07/20/2022] [Indexed: 11/13/2022] Open
Abstract
BackgroundAchieving maximal functionally safe resection of gliomas located within the eloquent speech areas is challenging, and there is a lack of literature on the combined use of 5-aminolevulinic acid (5-ALA) guidance and awake craniotomy.ObjectiveThe aim of this study was to describe our experience with the simultaneous use of 5-ALA fluorescence and awake speech mapping in patients with left frontal gliomas located within the vicinity of eloquent speech areas.Materials and methodsA prospectively collected database of patients was reviewed. 5-ALA was administered at a dose of 20 mg/kg 2 h prior to operation, and an operating microscope in BLUE400 mode was used to visualize fluorescence. All patients underwent surgery using the “asleep–awake–asleep” protocol with monopolar and bipolar electrical stimulation to identify the proximity of eloquent cortex and white matter tracts and to guide safe limits of resection along with fluorescence guidance. Speech function was assessed by a trained neuropsychologist before, during, and after surgery.ResultsIn 28 patients operated with cortical mapping and 5-ALA guidance (12 Grade 4, 6 Grade 3, and 10 Grade 2 gliomas), Broca’s area was identified in 23 cases and Wernicke’s area was identified in 5 cases. Fluorescence was present in 14 cases. Six tumors had residual fluorescence due to the positive speech mapping in the tumor bed. Transient aphasia developed in 14 patients, and permanent aphasia developed in 4 patients. In 6 patients operated with cortical and subcortical speech mapping and 5-ALA guidance (4 Grade 4, 1 Grade 3, and 1 Grade 2 gliomas), cortical speech areas were mapped in 5 patients and subcortical tracts were encountered in all cases. In all cases, resection was stopped despite the presence of residual fluorescence due to speech mapping findings. Transient aphasia developed in 6 patients and permanent aphasia developed in 4 patients. In patients with Grade 2–3 gliomas, targeted biopsy of focal fluorescence areas led to upgrading the grade and thus more accurate diagnosis.Conclusion5-ALA guidance during awake speech mapping is useful in augmenting the extent of resection for infiltrative high-grade gliomas and identifying foci of anaplasia in non-enhancing gliomas, while maintaining safe limits of functional resection based on speech mapping. Positive 5-ALA fluorescence in diffuse Grade 2 gliomas may be predictive of a more aggressive disease course.
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Affiliation(s)
- Sergey A. Goryaynov
- Departments of Neurotraumatology and Neurooncology, N.N.Burdenko National Medical Research Center of Neurosurgery, Moscow, Russia
- *Correspondence: Sergey A. Goryaynov,
| | - Svetlana B. Buklina
- Departments of Neurotraumatology and Neurooncology, N.N.Burdenko National Medical Research Center of Neurosurgery, Moscow, Russia
| | - Ivan V. Khapov
- I.M. Sechenov First Moscow State Medical University (Sechenov University), Moscow, Russia
| | - Artyom I. Batalov
- Departments of Neurotraumatology and Neurooncology, N.N.Burdenko National Medical Research Center of Neurosurgery, Moscow, Russia
| | - Alexander A. Potapov
- Departments of Neurotraumatology and Neurooncology, N.N.Burdenko National Medical Research Center of Neurosurgery, Moscow, Russia
| | - Igor N. Pronin
- Departments of Neurotraumatology and Neurooncology, N.N.Burdenko National Medical Research Center of Neurosurgery, Moscow, Russia
| | - Artem U. Belyaev
- Departments of Neurotraumatology and Neurooncology, N.N.Burdenko National Medical Research Center of Neurosurgery, Moscow, Russia
| | - Andrey A. Aristov
- Departments of Neurotraumatology and Neurooncology, N.N.Burdenko National Medical Research Center of Neurosurgery, Moscow, Russia
| | - Vadim U. Zhukov
- Departments of Neurotraumatology and Neurooncology, N.N.Burdenko National Medical Research Center of Neurosurgery, Moscow, Russia
| | - Galina V. Pavlova
- Departments of Neurotraumatology and Neurooncology, N.N.Burdenko National Medical Research Center of Neurosurgery, Moscow, Russia
- I.M. Sechenov First Moscow State Medical University (Sechenov University), Moscow, Russia
- Department of Neurogenetics, Institute of Higher Nervous Activity and Neurophysiology, Russian Academy of Sciences, Moscow, Russia
| | - Evgenii Belykh
- Department of Neurosurgery, New Jersey Medical School, Rutgers University, New Jersey, NJ, United States
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