Comparison of navigated 3D ultrasound findings with histopathology in subsequent phases of glioblastoma resection

Rygh, Ola M.; Selbekk, Tormod; Torp, Sverre Helge; Lydersen, Stian; Hernes, Toril A. Nagelhus; Unsgaard, Geirmund

doi:10.1007/s00701-008-0017-3

Cited by 94 publications

(74 citation statements)

References 32 publications

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“…Furthermore, it is known that the image resolution and quality of the ultrasound images decrease as resection proceeds. 26 This is primarily because of artifacts introduced by the surgical manipulation. Many strategies have been described to reduce these artifacts, making it possible to eliminate the majority.…”

Section: Discussionmentioning

confidence: 99%

Direct navigated 3D ultrasound for resection of brain tumors: a useful tool for intraoperative image guidance

Moiyadi¹,

Shetty²

2016

FOC

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OBJECTIVE Navigated 3D ultrasound is a novel intraoperative imaging adjunct permitting quick real-time updates to facilitate tumor resection. Image quality continues to improve and is currently sufficient to allow use of navigated ultrasound (NUS) as a stand-alone modality for intraoperative guidance without the need for preoperative MRI. METHODS The authors retrospectively analyzed cases involving operations performed at their institution in which a 3D ultrasound navigation system was used for control of resection of brain tumors in a “direct” 3D ultrasound mode, without preoperative MRI guidance. The usefulness of the ultrasound and its correlation with postoperative imaging were evaluated. RESULTS Ultrasound was used for resection control in 81 cases. In 53 of these 81 cases, at least 1 intermediate scan (range 1–3 intermediate scans) was obtained during the course of the resection, and in 50 of these 53 cases, the result prompted further resection. In the remaining 28 cases, intermediate scans were not performed either because the first ultrasound scan performed after resection was interpreted as showing no residual tumor (n = 18) and resection was terminated or because the surgeon intentionally terminated the resection prematurely due to the infiltrative nature of the tumor and extension of disease into eloquent areas (n = 10) and the final ultrasound scan was interpreted as showing residual disease. In an additional 20 cases, ultrasound navigation was used primarily for localization and not for resection control, making the total number of NUS cases where radical resection was planned 101. Gross-total resection (GTR) was planned in 68 of these 101 cases and cytoreduction in 33. Ultrasound-defined GTR was achieved in 51 (75%) of the cases in which GTR was planned. In the remaining 17, further resection had to be terminated (despite evidence of residual tumor on ultrasound) because of diffuse infiltration or proximity to eloquent areas. Of the 33 cases planned for cytoreduction, NUS guidance facilitated ultrasound-defined GTR in 4 cases. Overall, ultrasound-defined GTR was achieved in 50% of cases (55 of 111). Based on the postoperative imaging (MRI in most cases), GTR was achieved in 58 cases (53%). Final (postresection) ultrasonography was documented in 78 cases. The findings were compared with the postoperative imaging to ascertain concordance in detecting residual tumor. Overall concordance was seen in 64 cases (82.5%), positive concordance was seen in 33 (42.5%), and negative in 31 (40%). Discordance was seen in 14 cases—with ultrasound yielding false-positive results in 7 cases and false-negative results in 7 cases. Postoperative neurological worsening occurred in 15 cases (13.5%), and in most of these cases, it was reversible by the time of discharge. CONCLUSIONS The results of this study demonstrate that 3D ultrasound can be effectively used as a stand-alone navigation modality during the resection of brain tumors. The ability to provide repeated, high-quality intraoperative updates is useful for guiding resection. Attention to image acquisition technique and experience can significantly increase the quality of images, thereby improving the overall utility of this modality.

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Section: Discussionmentioning

confidence: 99%

Direct navigated 3D ultrasound for resection of brain tumors: a useful tool for intraoperative image guidance

Moiyadi¹,

Shetty²

2016

FOC

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“…The B-mode evaluation after subtotal tumor resection was not helpful in classifying a hyperechoic area as residual tumor, mainly because of artifacts and surgical manipulation 13,27,29,32,33 (Figs. 3-5).…”

Section: Discussionmentioning

confidence: 99%

“…6,7,16,18 Artifacts are in fact the main limitation in iUS B-mode interpretation in glioma surgery. 13,27,29,32,33 Surgical maneuvers inevitably lead to difficulty in ultrasound discrimination between residual tumor and surgically induced edema or artifacts. In particular, at the end of tumor resection it is difficult to assess if a hyperechoic area is actually residual tumor (Figs.…”

Section: Discussionmentioning

confidence: 99%

“…Moreover, because the surgical bed is not homogeneous but extremely indented, the ultrasound beam is subjected to reflection and transmission in a changeable manner. 13,27,29,32,33 To overcome these problems and to improve image quality, several solutions have been introduced. Thanks to the possibility of navigating the iUS probe, it is possible to compare the location of a hyperechoic area on iUS with the location of the tumor on preoperative MRI, when the studies are displayed in a coplanar fashion.…”

Section: Discussionmentioning

confidence: 99%

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Identification of residual tumor with intraoperative contrast-enhanced ultrasound during glioblastoma resection

Prada¹,

Bene²,

Fornaro³

et al. 2016

FOC

110

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OBJECTIVE The purpose of this study was to assess the capability of contrast-enhanced ultrasound (CEUS) to identify residual tumor mass during glioblastoma multiforme (GBM) surgery, to increase the extent of resection. METHODS The authors prospectively evaluated 10 patients who underwent surgery for GBM removal with navigated ultrasound guidance. Navigated B-mode and CEUS were performed prior to resection, during resection, and after complete tumor resection. Areas suspected for residual tumors on B-mode and CEUS studies were localized within the surgical field with navigated ultrasound and samples were sent separately for histopathological analysis to confirm tumor presence. RESULTS In all cases tumor remnants were visualized as hyperechoic areas on B-mode, highlighted as CEUS-positive areas, and confirmed as tumoral areas on histopathological analysis. In 1 case only, CEUS partially failed to demonstrate residual tumor because the residual hyperechoic area was devascularized prior to ultrasound contrast agent injection. In all cases CEUS enhanced B-mode findings. CONCLUSIONS As has already been shown in other neoplastic lesions in other organs, CEUS is extremely specific in the identification of residual tumor. The ability of CEUS to distinguish between tumor and artifacts or normal brain on B-mode is based on its capacity to show the vascularization degree and not the echogenicity of the tissues. Therefore, CEUS can play a decisive role in the process of maximizing GBM resection.

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“…6 As a result, the reliability of intraoperative ultrasonography has been questioned. 3,17,22 Intraoperative MRI is clearly the most reliable method for determining tumor margins during surgery. However, the equipment is expensive (approximately $3 million) 20 and therefore is only available in few institutions.…”

Section: Discussionmentioning

confidence: 99%

Intraoperative stereotactic injection of Indigo Carmine dye to mark ill-defined tumor margins: a prospective Phase I–II study

Margetis

Rajappa

Tsiouris

et al. 2015

JNS

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OBJECT A critical goal in neurosurgical oncology is maximizing the extent of tumor resection while minimizing the risk to normal white matter tracts. Frameless stereotaxy and white matter mapping are indispensable tools in this effort, but deep tumor margins may not be accurately defined because of the “brain shift” at the end of the operation. The authors investigated the safety and efficacy of a technique for marking the deep margins of intraaxial tumors with stereotactic injection of Indigo Carmine dye. METHODS Investigational New Drug study approval for a prospective study in adult patients with gliomas was obtained from the FDA (Investigational New Drug no. 112680). At surgery, 1–3 stereotactic injections of 0.01 ml of Indigo Carmine dye were performed through the initial bur holes into the deep tumor margins before elevation of the bone flap. White light microscopic resection was conducted in standard fashion by using frameless stereotactic navigation until the injected margins were identified. The resection of the injected tumor margins and the extent of resection of the whole tumor volume were determined by using postoperative volumetric MRI. RESULTS In total 17 injections were performed in 10 enrolled patients (6 male, 4 female), whose mean age was 49 years. For all patients, the injection points were identified intraoperatively and tumor was resected at these points. The staining pattern was reproducible; it was a sphere of stained tissue approximately 5 mm in diameter. A halo of stained tissue and a backflow of dye through the needle tract were also noted, but these were clearly distinct from the staining pattern of the injection point, which was vividly colored and demarcated. Postoperative MR images verified the resection of all injection points. The mean extent of resection of the tumor as a whole was 97.1%. For 1 patient, a brain abscess developed on postoperative Day 16 and needed additional surgical treatment. CONCLUSIONS Stereotactic injection of Indigo Carmine dye can be used to demarcate multiple deep tumor margins, which can be readily identified intraoperatively by using standard white light microscopy. This technique may enhance the accuracy of frameless stereotactic navigation and increase the extent of resection of intraaxial tumors.

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Comparison of navigated 3D ultrasound findings with histopathology in subsequent phases of glioblastoma resection

Cited by 94 publications

References 32 publications

Direct navigated 3D ultrasound for resection of brain tumors: a useful tool for intraoperative image guidance

Direct navigated 3D ultrasound for resection of brain tumors: a useful tool for intraoperative image guidance

Identification of residual tumor with intraoperative contrast-enhanced ultrasound during glioblastoma resection

Intraoperative stereotactic injection of Indigo Carmine dye to mark ill-defined tumor margins: a prospective Phase I–II study

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