Fluorescence Guided Surgery with 5-Aminolevulinic Acid for Resection of Spinal Cord Ependymomas

Moreno, Rafael García; García, Luis Ruiz; Bastidas, Hyaissa Ippolito; Tirado, Carlos Andrés Mondragón; Flores, Aurora Moreno; Cabezas, Juan Pablo Sosa; Artero, José Manuel Cabezudo

doi:10.31616/asj.2018.0165

Cited by 9 publications

(4 citation statements)

References 30 publications

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“…Our result of a strong fluorescence rate of 44% is similar to the existing literature [2,[33][34][35]. Our results of the ependymoma grade II group having a strong fluorescence rate of 83% with the grade III group having a 100% strong fluorescence rate is in line with the rate and extent of fluores- cence in clinical studies of both infratentorial [35] and spinal ependymomas [36], approaching 90 and 100% positive strong fluorescence for ependymoma grade II and grade III respectively [35,37,38]. Contrast enhancement was almost uniform across the entire cohort of tumours, only 2 (10%) tumours (a classic MB arising in the left lateral cerebellar hemisphere, and a classic MB arising in the midline from the roof of the fourth ventricle) failed to enhance post gadolinium administration.…”

Section: Discussionsupporting

confidence: 90%

“…Interestingly, in both ependymomas [38] and other non-glioma CNS tumours [74,75], the degree of fluorescence and proliferative index are not correlated, whereas in gliomas fluorescence increases proportionally with tumour grade and MIB-1 proliferative index [39,76,77]. Moschovi et al [59] and Bennetto et al [70] found a strong linear correlation between Ki-67 index and the density of new blood vessel formation in children with MB and posterior fossa ependymomas respectively.…”

Section: Discussionmentioning

confidence: 99%

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The Use of 5-Aminolevulinic Acid to Assist Gross Total Resection of Paediatric Posterior Fossa Tumours

Labuschagne

2020

Pediatr Neurosurg

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Background: 5-aminolevulinic acid (5-ALA) use is well established in the resection of adult high-grade gliomas. There is growing interest in its usefulness in the paediatric population. The potential benefit of 5-ALA-guided resection motivated our unit to offer the established adult protocol as off-label use. Objective: to determine if 5-ALA guided resection was routinely useful and offered increased gross total resection (GTR) results. Methods: Nineteen patients harbouring a posterior fossa tumour suggestive of either an ependymoma or medulloblastoma (MB) underwent surgery between January 2018 and October 2019. The mean age was 5 years (range 2–12 years). A dose of 20 mg/kg of 5-ALA (Gliolan®) was given 4 h preoperatively. Intraoperatively, the tumours were viewed under violet-blue light and the presence of fluorescence was recorded. Fluorescence status was compared with histopathological classification and grade, Ki-67 index, GTR rate, and a subjective determination of “usefulness” was determined. Results: The case series included ependymoma grade II (n = 6), ependymoma grade III (n = 4), and MB grade IV (n = 9). For the combined cohort, the strong fluorescence rate was 68% (n = 13), the heterogenous fluorescence rate was 26% (n = 5), and the completely negative fluorescence rate was 5% (n = 1). The strong fluorescence rate of 90% found in the combined ependymoma group compared to the 45% strong fluorescence rate in the MB group was statistically significant (p = 0.05). Within the MB group the Ki-67 index was found to be significantly higher in the strongly fluorescent group as opposed to the patchy or non-fluorescent group (77.5 vs. 40%, p = 0.016). Fluorescence was determined to be useful in 63% of all cases. There was no significant relationship between fluorescence and GTR. The relationship between perceived usefulness and resection was not statistically significant. No adverse drug reactions were recorded. Conclusion: This case series adds to the growing body of evidence demonstrating the safety of 5-ALA in the paediatric population. 5-ALA guided resection was found to be useful in the majority of cases but this did not correlate with GTR status. Ependymomas reliably fluoresce in 90% of cases, and 5-ALA-guided resection should be considered when a preoperative diagnosis of ependymoma is suspected.

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Section: Discussionsupporting

confidence: 90%

Section: Discussionmentioning

confidence: 99%

The Use of 5-Aminolevulinic Acid to Assist Gross Total Resection of Paediatric Posterior Fossa Tumours

Labuschagne

2020

Pediatr Neurosurg

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“…Whether GTR is successfully achieved or not is dependent upon the difficulty of tumor dissection and the adhesive change between the tumor and normal cord; however, it is impracticable to preoperatively predict the degree of adhesive change of tumor surfaces. To overcome this difficulty, intraoperative 5-aminolevulinic acid (5-ALA)-assisted resection of spinal cord ependymomas has recently been recommended [19]. We may utilize this 5-ALA-guided surgery at our institute in the near future.…”

Section: Discussionmentioning

confidence: 99%

Poor Prognostic Factors for Surgical Treatment of Spinal Intramedullary Ependymoma (World Health Organization Grade II)

et al. 2020

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Single-center retrospective study. Purpose: We aimed to explore the postoperative prognostic factors for spinal intramedullary ependymoma. Overview of Literature: Ependymoma (World Health Organization grade II) is the most frequent intramedullary spinal tumor and is treated by total resection. However, postoperative deterioration of motor function occasionally occurs. Methods: Eighty patients who underwent surgical resection at Keio University and Fujita Health University in Tokyo, Japan between 2003 and 2015 with more than 2 years of follow-up were enrolled. A good surgical result was defined as an improvement in the modified McCormick Scale score by one grade or more or having the same clinical grade as was observed preoperatively. Meanwhile, a poor result was defined as a reduction in the McCormick Scale score of one grade or more or remaining in grade IV or V at final follow-up. Univariate and multivariate logistic regression analyses of the following factors were performed in the two groups: sex, age, preoperative Visual Analog Scale (VAS), tumor location, the extent of tumor resection, hemosiderin caps, cavity length, and tumor length on magnetic resonance imaging. Results: At final follow-up, 15 patients were included in the poor results group and 65 in the good results group. In the univariate analysis, the factors related to poor results were as follows: higher age, preoperative McCormick Scale score severity, higher preoperative VAS, thoracic location, hemosiderin capped, and non-gross total resection (GTR). A multiple logistic regression analysis was conducted and showed that age, worse preoperative McCormick Scale score, and non-GTR were significant factors for poor prognosis. Conclusions: The independent risk factors for motor deterioration after ependymoma resection were age, worse preoperative Mc-Cormick Scale score, and non-GTR. Early surgery for patients with even mild neurological disorders could facilitate functional outcomes. These results may contribute to determining the optimal timing of surgery for spinal intramedullary ependymoma.

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“…Potentially of greater significance than histological diagnosis, tumor grade, or markers of proliferation [45,47,56] in predicting fluorescence may be the distinct genetic expression profile of the tumor. [5] In both glioma [1] and nonglioma CNS neoplasms, [61,70,71] differing molecular metabolism has been shown to be predictive of fluorescence rate.…”

Section: Discussionmentioning

confidence: 99%

5-aminolevulinic acid-guided surgery for focal pediatric brainstem gliomas: A preliminary study

Labuschagne¹

2020

Surgical Neurology International

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Background: There is a growing body of literature supporting the use of 5-aminolevulinic acid (5-ALA) in the pediatric population, however, its use is still considered “off label” in this setting. In this retrospective study, we report our experience using 5-ALA in pediatric patients with focal brainstem gliomas (BSGs). Methods: Patients younger than 16 years presenting with a newly diagnosed BSG that was focal in nature were considered suitable for treatment with 5-ALA-assisted surgery. Exclusion criteria included MRI features suggestive of a diffuse intrinsic pontine glioma. A single dose of 5-ALA was administered preoperatively. Intraoperative fluorescence was recorded as “solid,” “vague,” or “none.” The effectiveness of the fluorescence was graded as “helpful” or “unhelpful.” Results: Eight patients underwent 5-ALA-assisted surgery. There were four tumors located in the pons, two midbrain tumors, and two cervicomedullary tumors. Histological analysis demonstrated three diffuse astrocytomas, three pilocytic astrocytomas, and two anaplastic astrocytomas. Solid fluorescence was found in three of the eight cases, vague fluorescence was found in two cases, and no fluorescence was found in three cases. Fluorescence was useful in 3 (37%) cases. No patients experienced any complications attributable to the administration of the 5-ALA. Conclusion: With a total fluorescence rate of 62.5% but a subjectively assessed “usefulness” rate of only 37.5%, the role of 5-ALA in BSG surgery is limited. Given the toxicological safety, however, of the agent, caution is perhaps needed before dismissing the use of 5-ALA entirely.

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Fluorescence Guided Surgery with 5-Aminolevulinic Acid for Resection of Spinal Cord Ependymomas

Cited by 9 publications

References 30 publications

The Use of 5-Aminolevulinic Acid to Assist Gross Total Resection of Paediatric Posterior Fossa Tumours

The Use of 5-Aminolevulinic Acid to Assist Gross Total Resection of Paediatric Posterior Fossa Tumours

Poor Prognostic Factors for Surgical Treatment of Spinal Intramedullary Ependymoma (World Health Organization Grade II)

5-aminolevulinic acid-guided surgery for focal pediatric brainstem gliomas: A preliminary study

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