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Fluorescence-guided surgery in high grade gliomas using an exoscope system

  • Clinical Article - Neurosurgical Techniques
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Abstract

Background

Fluorescence-guided microsurgical resections of high-grade gliomas using 5-aminolevulinic acid (5-ALA) is superior to conventional microsurgery. An optical device, usually a modified microscope, is needed for these procedures. However, an exoscope may be implemented for fluorescence techniques. We present the use of an exoscope to perform tumor resection guided by 5-ALA fluorescence in 21 consecutive patients with high-grade glioma and two neuronavigation-guided biopsies.

Methods

Twenty-three patients underwent operations. Tumor volume and localization were quantified with pre- and postoperative volumetric MRI in non-biopsy cases.

Results

In non-biopsy cases, the age range was 20 to 79 years, with a median of 56 (interquartile range = 45-66). Histological analysis indicated that 14 had glioblastoma multiforme, 2 grade-III oligodendrogliomas and 1 anaplastic astrocytoma, 3 metastases and 1 low-grade astrocytoma. Total resection was achieved in 15 cases; subtotal resection was performed in 5 patients. The result was partial resection in one case. There was no perioperative mortality. The median fluorescence intensity, on a scale of 1–5, was 4.5 in the GBM group (IQR = 4-5), 3 (IQR = 2.5-3.5) in anaplastic glioma, and 2.5 (IQR = 2.25-2.75) for oligodendrogliomas. Of the three metastases, one showed fluorescence level 4. As for the two biopsy cases, one was anaplastic astrocytoma and one glioblastoma multiforme. The samples obtained were fluorescent in both cases.

Conclusions

An exoscope can be also used for fluorescence-guided surgery with 5-aminolevulinic acid (5-ALA) and neuronavigation-guided biopsy. With an important advantage of low cost, this allows the surgeon to perform collaborative surgeries and adds agility to the procedure.

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References

  1. Louis DN, Ohgaki H, Wiestler OD, Cavenee WK, Burger PC, Jouvet A, Scheithauer BW, Kleihues P (2007) The 2007 WHO classification of tumours of the central nervous system. Acta Neuropathol 114:97–109

    Google Scholar 

  2. Pichlmeier U, Bink A, Schackert G, Stummer W (2008) Resection and survival in glioblastoma multiforme: an RTOG recursive partitioning analysis of ALA study patients. Neuro Oncol 10:1025–1034

    Google Scholar 

  3. Sanai N, Berger MS (2012) Recent surgical management of gliomas. Adv Exp Med Biol 746:12–25

    Google Scholar 

  4. Stummer W, Reulen HJ, Meinel T, Pichlmeier U, Schumacher W, Tonn JC, Rohde V, Oppel F, Turowski B, Woiciechowsky C, Franz K, Pietsch T (2008) Extent of resection and survival in glioblastoma multiforme: identification of and adjustment for bias. Neurosurgery 62:564–576, discussion 564–576

    Google Scholar 

  5. Philip-Ephraim EE, Eyong KI, Williams UE, Ephraim RP (2012) The role of radiotherapy and chemotherapy in the treatment of primary adult high grade gliomas: assessment of patients for these treatment approaches and the common immediate side effects. ISRN Oncol 2012:902178

  6. Yamaguchi S, Kobayashi H, Terasaka S, Ishii N, Ikeda J, Kanno H, Nishihara H, Tanaka S, Houkin K (2012) The impact of extent of resection and histological subtype on the outcome of adult patients with high-grade gliomas. Jpn J Clin Oncol 42:270–277

    Google Scholar 

  7. Wang Y, Jiang T (2013) Understanding high grade glioma: molecular mechanism, therapy and comprehensive management. Cancer letters

  8. Diez Valle R, Tejada Solis S, Idoate Gastearena MA, Garcia de Eulate R, Dominguez Echavarri P, Aristu Mendiroz J (2011) Surgery guided by 5-aminolevulinic fluorescence in glioblastoma: volumetric analysis of extent of resection in single-center experience. J Neurooncol 102:105--113

    Google Scholar 

  9. Panciani PP, Fontanella M, Garbossa D, Agnoletti A, Ducati A, Lanotte M (2012) 5-aminolevulinic acid and neuronavigation in high-grade glioma surgery: results of a combined approach. Neurocirugia (Astur) 23:23--28

    Google Scholar 

  10. Roberts DW, Valdes PA, Harris BT, Hartov A, Fan X, Ji S, Pogue BW, Leblond F, Tosteson TD, Wilson BC, Paulsen KD (2012) Adjuncts for maximizing resection: 5-aminolevuinic acid. Clin Neurosurg 59:75--78

    Google Scholar 

  11. Stummer W, Pichlmeier U, Meinel T, Wiestler OD, Zanella F, Reulen H-J (2006) Fluorescence-guided surgery with 5-aminolevulinic acid for resection of malignant glioma: a randomised controlled multicentre phase III trial. Lancet Oncol 7:392--401

    Google Scholar 

  12. von Campe G, Moschopulos M, Hefti M (2012) 5-Aminolevulinic acid-induced protoporphyrin IX fluorescence as immediate intraoperative indicator to improve the safety of malignant or high-grade brain tumor diagnosis in frameless stereotactic biopsies. Acta Neurochir (Wien) 154:585–588, discussion 588

    Google Scholar 

  13. Bernal-Garcia LM, Cabezudo-Artero JM, Ortega-Martinez M, Fernandez-Portales I, Gimenez-Pando J, Ugarriza-Echebarrieta LF, Mata-Gomez J, Molina-Orozco M, Malca-Balcazar JF (2010) Fluorescence-guided resection with 5-aminolevulinic acid of an intramedullary tumor. Neurocirugia (Astur) 21:312–316

    Google Scholar 

  14. Panciani PP, Fontanella M, Schatlo B, Garbossa D, Agnoletti A, Ducati A, Lanotte M (2012) Fluorescence and image guided resection in high grade glioma. Clin Neurol Neurosurg 114:37–41

    Google Scholar 

  15. Potapov AA, Usachev DJ, Loshakov VA, Cherekaev VA, Kornienko VN, Pronin IN, Kobiakov GL, Kalinin PL, Gavrilov AG, Stummer W, Golbin DA, Zelenkov PV (2008) First experience in 5-ALA fluorescence-guided and endoscopically assisted microsurgery of brain tumors. Med Laser Appl 23:202–208

    Google Scholar 

  16. Gildenberg PL, Ledoux R, Cosman E, Labuz J (1994) The exoscope--a frame-based video/graphics system for intraoperative guidance of surgical resection. Stereotac Funct Neurosurg 63:23–25

  17. Mamelak AN, Danielpour M, Black KL, Hagike M, Berci G (2008) A high-definition exoscope system for neurosurgery and other microsurgical disciplines: preliminary report. Surg Innov 15:38–46

    Google Scholar 

  18. Mamelak AN, Nobuto T, Berci G (2010) Initial clinical experience with a high-definition exoscope system for microneurosurgery. Neurosurg 67:476–483

    Google Scholar 

  19. Eljamel MS (2008) Fluorescence image-guided surgery of brain tumors: explained step-by-step. Photodiagnosis and Photodynamic Therapy 5:260–263

    Google Scholar 

  20. Widhalm G, Minchev G, Woehrer A, Preusser M, Kiesel B, Furtner J, Mert A, Di Ieva A, Tomanek B, Prayer D, Marosi C, Hainfellner JA, Knosp E, Wolfsberger S (2012) Strong 5-aminolevulinic acid-induced fluorescence is a novel intraoperative marker for representative tissue samples in stereotactic brain tumor biopsies. Neurosurg Rev 35:381–391, discussion 391

    Google Scholar 

  21. Shinoda J, Sakai N, Murase S, Yano H, Matsuhisa T, Funakoshi T (2001) Selection of eligible patients with supratentorial glioblastoma multiforme for gross total resection. J Neurooncol 52:161–171

    Google Scholar 

  22. Colditz MJ, Jeffree RL (2012) Aminolevulinic acid (ALA)-protoporphyrin IX fluorescence guided tumour resection. Part 1: Clinical, radiological and pathological studies. J Clin Neurosci 19:1471–1474

    Google Scholar 

  23. Cortnum S, Laursen RJ (2012) Fluorescence-guided resection of gliomas. Dan Med J 59:A4460

    Google Scholar 

  24. Nabavi A, Thurm H, Zountsas B, Pietsch T, Lanfermann H, Pichlmeier U, Mehdorn M (2009) Five-aminolevulinic acid for fluorescence-guided resection of recurrent malignant gliomas: a phase ii study. Neurosurg 65:1070–1076, discussion 1076–1077

    Google Scholar 

  25. Roessler K, Becherer A, Donat M, Cejna M, Zachenhofer I (2012) Intraoperative tissue fluorescence using 5-aminolevolinic acid (5-ALA) is more sensitive than contrast MRI or amino acid positron emission tomography ((18)F-FET PET) in glioblastoma surgery. Neurol Res 34:314–317

    Google Scholar 

  26. Tykocki T, Michalik R, Bonicki W, Nauman P (2012) Fluorescence-guided resection of primary and recurrent malignant gliomas with 5-aminolevulinic acid. Preliminary results. Neurologia i neurochirurgia polska 46:47–51

    Google Scholar 

  27. Carlucci C, Fasanella L, Ricci Maccarini A (2012) Exolaryngoscopy: a new technique for laryngeal surgery. Acta otorhinolaryngologica Italica : organo ufficiale della Societa italiana di otorinolaringologia e chirurgia cervico-facciale 32:326–328

    Google Scholar 

  28. Shirzadi A, Mukherjee D, Drazin DG, Paff M, Perri B, Mamelak AN, Siddique K (2012) Use of the video telescope operating monitor (VITOM) as an alternative to the operating microscope in spine surgery. Spine 37:E1517–1523

    Google Scholar 

  29. Wiwanitkit V (2012) VITOM in digital high-definition video exocolposcopy. Journal of lower genital tract disease 16:480, author reply 480–481

    Google Scholar 

  30. Rapp M, Kamp M, Steiger HJ, Sabel M (2013) Endoscopic-assisted visualization of 5-Aminolevulinic acid-induced fluorescence in malignant glioma surgery: a technical note. World Neurosurg. doi:10.1016/j.wneu.2013.07.002

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Acknowledgments

The authors thank Dr. Blanca Piedrafita and the team of Medical Statistics Consulting (Valencia, Spain) for the editorial support.

Conflict of Interest

The authors declare no conflicts of interest in relation to the contents of this manuscript.

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Authors and Affiliations

  1. Neurosurgery Service, Hospital de la Ribera, Carretera Corbera, 46600, Alzira, Valencia, Spain

    José Piquer Belloch, Vicente Rovira, Jose L. Llácer & Pedro A. Riesgo

  2. Pathology Service, Hospital de la Ribera, Alzira, Spain

    Antonio Cremades

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  1. José Piquer Belloch
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  2. Vicente Rovira
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  3. Jose L. Llácer
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Correspondence to José Piquer Belloch.

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Belloch, J.P., Rovira, V., Llácer, J.L. et al. Fluorescence-guided surgery in high grade gliomas using an exoscope system. Acta Neurochir 156, 653–660 (2014). https://doi.org/10.1007/s00701-013-1976-6

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  • DOI: https://doi.org/10.1007/s00701-013-1976-6

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