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Tricks and traps of ICG endoscopy for effectively applying endoscopic transsphenoidal surgery to pituitary adenoma

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Abstract

Differentiating tumor from normal pituitary gland is very important for achieving complete resection without complications in endoscopic endonasal transsphenoidal surgery (ETSS) for pituitary adenoma. To facilitate such surgery, we investigated the utility of indocyanine green (ICG) fluorescence endoscopy as a tool in ETSS. Twenty-four patients with pituitary adenoma were enrolled in the study and underwent ETSS using ICG endoscopy. After administering 12.5 mg of ICG twice an operation with an interval > 30 min, times from ICG administration to appearance of fluorescence on vital structures besides the tumor were measured. ICG endoscopy identified vital structures by the phasic appearance of fluorescent signals emitted at specific consecutive elapsed times. Elapsed times for internal carotid arteries did not differ according to tumor size. Conversely, as tumor size increased, elapsed times for normal pituitary gland were prolonged but those for the tumor were reduced. ICG endoscopy revealed a clear boundary between tumors and normal pituitary gland and enabled confirmation of no more tumor. ICG endoscopy could provide a useful tool for differentiating tumor from normal pituitary gland by evaluating elapsed times to fluorescence in each structure. This method enabled identification of the boundary between tumor and normal pituitary gland under conditions of a low-fluorescence background, resulting in complete tumor resection with ETSS. ICG endoscopy will contribute to improve the resection rate while preserving endocrinological functions in ETSS for pituitary adenoma.

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References

  1. Amano K, Aihara Y, Tsuzuki S, Okada Y, Kawamata T (2019) Application of indocyanine green fluorescence endoscopic system in transsphenoidal surgery for pituitary tumors. Acta Neurochir 161(4):695–706

    Article  Google Scholar 

  2. Bruneau M, Appelboom G, Rynkowski M, Van Cutsem N, Mine B, De Witte O (2013) Endoscope-integrated ICG technology: first application during intracranial aneurysm surgery. Neurosurg Rev 36(1):77–85

    PubMed  Google Scholar 

  3. Cappabianca P, Alfieri A, Thermes S, Buonamassa S, de Divitiis E (1999) Instruments for endoscopic endonasal transsphenoidal surgery. Neurosurgery 45(2):392–395

    Article  CAS  Google Scholar 

  4. Catapano D, Sloffer CA, Frank G, Pasquini E, D’Angelo VA, Lanzino G (2006) Comparison between the microscope and endoscope in the direct endonasal extended transsphenoidal approach: anatomical study. J Neurosurg 104(3):419–425

    Article  Google Scholar 

  5. Della Puppa A, Rustemi O, Gioffrè G, Causin F, Scienza R (2014) Transdural indocyanine green video-angiography of vascular malformations. Acta Neurochir 156(9):1761–1767

    Article  Google Scholar 

  6. Della Puppa A, Rustemi O, Rossetto M, Gioffrè G, Munari M, Charbel FT, Scienza R (2014) The “squeezing maneuver” in microsurgical clipping of intracranial aneurysms assisted by indocyanine green videoangiography. Neurosurgery 10(Suppl 2):208–213

    PubMed  Google Scholar 

  7. Della Puppa A, Rustemi O, Scienza R (2016) Intraoperative flow measurement by microflow probe during spinal dural arteriovenous fistula surgery. World Neurosurg 89:413–419

    Article  Google Scholar 

  8. Della Puppa A, Rossetto M, Volpin F, Rustemi O, Grego A, Gerardi A, Ortolan R, Causin F, Munari M, Scienza R (2018) Microsurgical clipping of intracranial aneurysms assisted by neurophysiological monitoring, microvascular flow probe, and ICG-VA: outcomes and intraoperative data on a multimodal strategy. World Neurosurg 113:e336–e344

    Article  Google Scholar 

  9. Frank G, Pasquini E, Farneti G, Mazzatenta D, Sciarretta V, Grasso V, Faustini Fustini M (2006) The endoscopic versus the traditional approach in pituitary surgery. Neuroendocrinology 83(3–4):240–248

    Article  CAS  Google Scholar 

  10. Hide T, Yano S, Shinojima N, Kuratsu J (2015) Usefulness of the indocyanine green fluorescence endoscope in endonasal transsphenoidal surgery. J Neurosurg 122(5):1185–1192

    Article  Google Scholar 

  11. Inoue A, Ohnishi T, Kohno S, Harada H, Nishikawa M, Ozaki S, Matsumoto S, Ohue S (2015) Utility of three-dimensional computed tomography for anatomical assistance in endoscopic endonasal transsphenoidal surgery. Neurosurg Rev 38(3):559–565

    Article  Google Scholar 

  12. Inoue A, Ohnishi T, Kohno S, Nishida N, Nakamura Y, Ohtsuka Y, Matsumoto S, Ohue S (2015) Usefulness of an image fusion model using three-dimensional CT and MRI with indocyanine green fluorescence endoscopy as a multimodal assistant system in endoscopic transsphenoidal surgery. Int J Endocrinol 694273

  13. Jankowski R, Auque J, Simon C, Marchal JC, Hepner H, Wayoff M (1992) Endoscopic pituitary tumor surgery. Laryngoscope 102(2):198–202

    Article  CAS  Google Scholar 

  14. Jho HD, Alfieri A (2001) Endoscopic endonasal pituitary surgery: evolution of surgical technique and equipment in 150 operations. Minim Invasive Neurosurg 44(1):1–12

    Article  CAS  Google Scholar 

  15. Litvack ZN, Zada G, Laws ER Jr (2012) Indocyanine green fluorescence endoscopy for visual differentiation of pituitary tumor from surrounding structures. J Neurosurg 116(5):935–941

    Article  Google Scholar 

  16. Nishiyama Y, Kinouchi H, Senbokuya N, Kato T, Kanemaru K, Yoshioka H, Horikoshi T (2012) Endoscopic indocyanine green video angiography in aneurysm surgery: an innovative method for intraoperative assessment of blood flow in vasculature hidden from microscopic view. J Neurosurg 117(2):302–308

    Article  Google Scholar 

  17. Raabe A, Nakaji P, Beck J, Kim LJ, Hsu FP, Kamerman JD, Seifert V, Spetzler RF (2005) Prospective evaluation of surgical microscope integrated intraoperative near-infrared indocyanine green videoangiography during aneurysm surgery. J Neurosurg 103(6):982–989

    Article  Google Scholar 

  18. Sandow N, Klene W, Elbelt U, Strasburger CJ, Vajkoczy P (2015) Intraoperative indocyanine green videoangiography for identification of pituitary adenomas using a microscopic transsphenoidal approach. Pituitary 18(5):613–620

    Article  CAS  Google Scholar 

  19. Schuette AJ, Cawley CM, Barrow DL (2010) Indocyanine green videoangiography in the management of dural arteriovenous fistulae. Neurosurgery 67(3):658–662

    Article  Google Scholar 

  20. Suzuki K, Kodama N, Sasaki T, Matsumoto M, Ichikawa T, Munakata R, Muramatsu H, Kasuya H (2007) Confirmation of blood flow in perforating arteries using fluorescein cerebral angiography during aneurysm surgery. J Neurosurg 107(1):68–73

    Article  Google Scholar 

  21. van Cauwenberge P, Calliauw L (1983) The transethmoidal-transsphenoidal route to the pituitary gland. Technique, advantages, limitations and possible complications. Acta Otorhinolaryngol Belg 37(6):883–891

    PubMed  Google Scholar 

  22. Verstegen MJT, Tummers QRJG, Schutte PJ, Pereira AM, van Furth WR, van de Velde CJH, Malessy MJA, Vahrmeijer AL (2016) Intraoperative identification of a normal pituitary gland and an adenoma using near-infrared fluorescence imaging and low-dose indocyanine green. Oper Neurosurg (Hagerstown) 12(3):260–268

    Article  Google Scholar 

  23. Yaniv E, Rappaport ZH (1997) Endoscopic transseptal transsphenoidal surgery for pituitary tumors. Neurosurgery 40(5):944–946

    Article  CAS  Google Scholar 

Download references

Acknowledgments

We would like to express our gratitude to Taichi Furumochi and Yasuhiro Shiraishi of the Department of Neurology, Ehime University Hospital, Japan; and Satsuki Myoga of the Department of Pathology, Ehime University Hospital, Japan, for their help in obtaining pathological and radiological findings.

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Authors and Affiliations

  1. Department of Neurosurgery, Ehime University School of Medicine, 454 Shitsukawa, Toon, Ehime, 791-0295, Japan

    Akihiro Inoue, Shohei Kohno, Satoshi Suehiro, Yawara Nakamura, Shirabe Matsumoto, Masahiro Nishikawa, Saya Ozaki, Seiji Shigekawa, Hideaki Watanabe & Takeharu Kunieda

  2. Department of Neurosurgery, Washoukai Sadamoto Hospital, 1-6-1 Takehara, Matsuyama, Ehime, 790-0052, Japan

    Takanori Ohnishi

  3. Department of Otolaryngology, Ehime University School of Medicine, 454 Shitsukawa, Toon, Ehime, 791-0295, Japan

    Naoya Nishida

  4. Department of Lifestyle-Related Medicine and Endocrinology, Ehime University School of Medicine, 454 Shitsukawa, Toon, Ehime, 791-0295, Japan

    Hidenori Senba, Hironobu Nakaguchi & Bunzo Matsuura

  5. Division of Diagnostic Pathology, Ehime University Hospital, 454 Shitsukawa, Toon, Ehime, 791-0295, Japan

    Mashio Taniwaki & Riko Kitazawa

Authors
  1. Akihiro Inoue
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  2. Shohei Kohno
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  3. Takanori Ohnishi
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  11. Hideaki Watanabe
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  12. Hidenori Senba
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  13. Hironobu Nakaguchi
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  14. Mashio Taniwaki
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  15. Bunzo Matsuura
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  16. Riko Kitazawa
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  17. Takeharu Kunieda
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Corresponding author

Correspondence to Akihiro Inoue.

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The authors declare that they have no conflict of interest.

Research involving human participants

This study was approved by the Ethics Committee for Clinical Research at Ehime University Hospital (No. 2004017) prior to initiation, and was performed in accordance with the ethical standards as laid down in the 1964 Declaration of Helsinki and its later amendments.

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Informed consent was obtained from all individual participants included in the study.

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Inoue, A., Kohno, S., Ohnishi, T. et al. Tricks and traps of ICG endoscopy for effectively applying endoscopic transsphenoidal surgery to pituitary adenoma. Neurosurg Rev 44, 2133–2143 (2021). https://doi.org/10.1007/s10143-020-01382-4

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  • DOI: https://doi.org/10.1007/s10143-020-01382-4

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