Fluorescein-guided surgery for grade IV gliomas with a dedicated filter on the surgical microscope: preliminary results in 12 cases

Acerbi, Francesco; Broggi, Morgan; Eoli, Marica; Anghileri, Elena; Cuppini, Lucia; Pollo, Bianca; Schiariti, Marco; Visintini, Sergio; Orsi, Chiara; Franzini, Angelo; Broggi, Giovanni; Ferroli, Paolo

doi:10.1007/s00701-013-1734-9

Cited by 130 publications

(113 citation statements)

References 26 publications

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“…The emergence of surgical microscopes outfitted with a fluorescein-specific filter has enabled broader application of fluorescein guidance to glioma microsurgery 2,17,26 with a statistically strong association between fluorescein staining and tumor tissue, as well as reports that fluorescein guidance safely facilitates complete resection of contrast-enhancing (CE) tumor. 1,9 However, small study groups have offered limited evidence of the added utility of fluorescein guidance, and rigorous assessment of fluorescein as a marker for tumor pathology in regions beyond MRI contrast enhancement has not been performed.…”

Section: 27mentioning

confidence: 99%

“…1,9 However, small study groups have offered limited evidence of the added utility of fluorescein guidance, and rigorous assessment of fluorescein as a marker for tumor pathology in regions beyond MRI contrast enhancement has not been performed. 2,9 In the present study, we evaluate the utility of intraoperative fluorescein imaging for identification of neoplastic tissue, present analytical methods for robust quantification of fluorescein intensity, and assess the correlation of fluorescein staining with histopathological alteration in radiographically localized biopsies, especially as it pertains to regions of nonenhancing tumor. In addition, we corroborate earlier reports of high patient safety, ease of administration, and subjective utility.…”

Section: 27mentioning

confidence: 99%

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Aggressive resection at the infiltrative margins of glioblastoma facilitated by intraoperative fluorescein guidance

Neira

Ung

Sims

et al. 2017

Journal of Neurosurgery

126

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ABBREVIATIONS 5-ALA = 5-aminolevulinic acid; BBB = blood-brain barrier; CE = contrast enhancing; CUMC = Columbia University Medical Center; EOR = extent of resection; GBM = glioblastoma; GTR = gross-total resection; HGG = high-grade glioma; n-ANOVA = multiway ANOVA; NCE = non-contrast enhancing; OS = overall survival; PFS = progression-free survival; PPV = positive predictive value; ROI = region of interest; STR = subtotal resection; UD = undetermined; WHO = World Health Organization; Y560 = YELLOW 560. OBJECTIVE Extent of resection is an important prognostic factor in patients undergoing surgery for glioblastoma (GBM). Recent evidence suggests that intravenously administered fluorescein sodium associates with tumor tissue, facilitating safe maximal resection of GBM. In this study, the authors evaluate the safety and utility of intraoperative fluorescein guidance for the prediction of histopathological alteration both in the contrast-enhancing (CE) regions, where this relationship has been established, and into the non-CE (NCE), diffusely infiltrated margins. METHODS Thirty-two patients received fluorescein sodium (3 mg/kg) intravenously prior to resection. Fluorescence was intraoperatively visualized using a Zeiss Pentero surgical microscope equipped with a YELLOW 560 filter. Stereotactically localized biopsy specimens were acquired from CE and NCE regions based on preoperative MRI in conjunction with neuronavigation. The fluorescence intensity of these specimens was subjectively classified in real time with subsequent quantitative image analysis, histopathological evaluation of localized biopsy specimens, and radiological volumetric assessment of the extent of resection. RESULTS Bright fluorescence was observed in all GBMs and localized to the CE regions and portions of the NCE margins of the tumors, thus serving as a visual guide during resection. Gross-total resection (GTR) was achieved in 84% of the patients with an average resected volume of 95%, and this rate was higher among patients for whom GTR was the surgical goal (GTR achieved in 93.1% of patients, average resected volume of 99.7%). Intraoperative fluorescein staining correlated with histopathological alteration in both CE and NCE regions, with positive predictive values by subjective fluorescence evaluation greater than 96% in NCE regions. CONCLUSIONS Intraoperative administration of fluorescein provides an easily visualized marker for glioma pathology in both CE and NCE regions of GBM. These findings support the use of fluorescein as a microsurgical adjunct for guiding GBM resection to facilitate safe maximal removal. SUBMITTEDhttps://thejns.org/doi/abs/10.3171/2016.7.JNS16232

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Section: 27mentioning

confidence: 99%

Section: 27mentioning

confidence: 99%

Aggressive resection at the infiltrative margins of glioblastoma facilitated by intraoperative fluorescein guidance

Neira

Ung

Sims

et al. 2017

Journal of Neurosurgery

126

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“…Technical and technological advances in the last two decades have greatly contributed to the customization and management of the different surgical pathologies that can be located in the pons. Refinement of preoperative MRI with advanced techniques (mainly DTI, which provides a thorough topographical anatomical view of the nuclei and fasciculi of the crucial nerves), 6,7,40 the introduction of virtual 3D surgical planning, 11,12 fluorescence-guided surgery, 1,35 and improved electrophysiological monitoring 31 have all significantly combined to allow the surgeon to calibrate the surgery to the specific patient's anatomy and, in so doing, to reduce the impact of brainstem surgery on the patient's quality of life. These innovations, combined with a remarkable growth of interest in the neurosurgical community in this topic, have led to a reconsideration of the classic suboccipital posterior midline approach through the floor of the fourth ventricle and to an acceleration in the development of alternative multidisciplinary approaches to skull base techniques.…”

Section: Discussionmentioning

confidence: 99%

The lateral infratrigeminal transpontine window to deep pontine lesions

Ferroli

Schiariti

Cordella

et al. 2015

JNS

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S urgery of intraaxial brainstem lesions has been shown to be feasible and is now being performed in selected patients despite the risk of functional brainstem damage. 4,15,20,31 There are many variables that affect the results of this surgery such as patient selection, surgical techniques, and available technologies. In addition, there is currently no consensus surrounding the decision-making process that guides the surgeon to choose this approach. This is particularly true when this surgery is under consideration for deep pontine lesions that require a brainstem incision to be exposed. In fact, the pons remains one of the most protected and inaccessible areas of the brain because its exposition is obstructed by the cerebellum posteriorly, by the petrous bone laterally, and by septic nasal cavities abbreviatioNs CMAP = compound muscle action potential; CN = cranial nerve; DTI = diffusion tensor imaging; GTR = gross-total resection; MEP = motor evoked potential; mRS = modified Rankin Scale; SSEP = somatosensory evoked potential; STR = subtotal resection.

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“…Most studies in 5-ALA-guided neurosurgery have been performed using fluorescence microscopy [35][36][37][38].…”

Section: Fluorescence Imaging Instrumentationmentioning

confidence: 99%

Review of Neurosurgical Fluorescence Imaging Systems for Clinical Application

Kim

Lee

Yoo

et al. 2016

Journal of the Optical Society of Korea

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A number of fluorescence imaging techniques for use in the surgical removal of glioma have been developed over the course of the long history of neurosurgery. Various biomarkers, biochemical agents, and detection systems for glioma have also been developed. This review focuses on 5-aminolevulinic acid (5-ALA), which is used to detect glioma. Numerous forms of fluorescence-guided surgery use 5-ALA, which is helpful to the surgeon. The surgical microscope system is the observational method generally used with 5-ALA, while the loupe, endoscope, and exoscope are simpler alternatives. A system is needed for minimal resection and other issues that arise during neurosurgery. Such an enhanced system should be able to detect low-grade tumors and provide information on microinvasive diseases, resulting in an improved survival rate and better surgical skills. Development of systems that fulfill certain needs would help protect the brain function of the patient and broaden the use of such systems in neurosurgery.

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Fluorescein-guided surgery for grade IV gliomas with a dedicated filter on the surgical microscope: preliminary results in 12 cases

Abstract: This preliminary analysis suggested that the use of intravenous fluorescein during surgery on grade IV gliomas is safe and allows a high rate of complete resection of contrast-enhanced tumor at the early postoperative MRI.

Cited by 130 publications

References 26 publications

Aggressive resection at the infiltrative margins of glioblastoma facilitated by intraoperative fluorescein guidance

Aggressive resection at the infiltrative margins of glioblastoma facilitated by intraoperative fluorescein guidance

The lateral infratrigeminal transpontine window to deep pontine lesions

Review of Neurosurgical Fluorescence Imaging Systems for Clinical Application

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