Emerging operative strategies in neurosurgical oncology

Sanai, Nader

doi:10.1097/wco.0b013e32835a2574

Cited by 28 publications

(15 citation statements)

References 114 publications

(131 reference statements)

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“…Recent studies investigating 5-ALA fluorescence in low-grade gliomas have shown positivity without use of any magnification in only 17% (n = 1/6) of patients, 44 whereas a positive rate of 100% (n = 10/10) could be demonstrated with the use of confocal microscopy. 33,35 Ewelt et al 10 found 7.7% (n = 1/13) and Widhalm et al 48 found no focal 5-ALA fluorescence in WHO Grade II tumors (n = 0/8). The authors of smaller series reported a lack of 5-ALA fluorescence in low-grade gliomas.…”

Section: -Ala Fluorescence In Primary Brain Tumorsmentioning

confidence: 99%

Use of fluorescence to guide resection or biopsy of primary brain tumors and brain metastases

Marbacher

Klinger

Schwyzer

et al. 2014

FOC

141

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Object The accurate discrimination between tumor and normal tissue is crucial for determining how much to resect and therefore for the clinical outcome of patients with brain tumors. In recent years, guidance with 5-aminolevulinic acid (5-ALA)–induced intraoperative fluorescence has proven to be a useful surgical adjunct for gross-total resection of high-grade gliomas. The clinical utility of 5-ALA in resection of brain tumors other than glioblastomas has not yet been established. The authors assessed the frequency of positive 5-ALA fluorescence in a cohort of patients with primary brain tumors and metastases. Methods The authors conducted a single-center retrospective analysis of 531 patients with intracranial tumors treated by 5-ALA–guided resection or biopsy. They analyzed patient characteristics, preoperative and postoperative liver function test results, intraoperative tumor fluorescence, and histological data. They also screened discharge summaries for clinical adverse effects resulting from the administration of 5-ALA. Intraoperative qualitative 5-ALA fluorescence (none, mild, moderate, and strong) was documented by the surgeon and dichotomized into negative and positive fluorescence. Results A total of 458 cases qualified for final analysis. The highest percentage of 5-ALA–positive fluorescence in open resection was found in glioblastomas (96%, n = 99/103). Among other tumors, 5-ALA–positive fluorescence was detected in 88% (n = 21/32) of anaplastic gliomas (WHO Grade III), 40% (n = 8/19) of low-grade gliomas (WHO Grade II), no (n = 0/3) WHO Grade I gliomas, and 77% (n = 85/110) of meningiomas. Among metastases, the highest percentage of 5-ALA–positive fluorescence was detected in adenocarcinomas (48%, n = 13/27). Low rates or absence of positive fluorescence was found among pituitary adenomas (8%, n = 1/12) and schwannomas (0%, n = 0/7). Biopsies of high-grade primary brain tumors showed positive rates of fluorescence similar to those recorded for open resection. No clinical adverse effects associated with use of 5-ALA were observed. Only 1 patient had clinically silent transient elevation of liver enzymes. Conclusions Study findings suggest that the administration of 5-ALA as a surgical adjunct for resection and biopsy of primary brain tumors and brain metastases is safe. In light of the high rate of positive fluorescence in high-grade gliomas other than glioblastomas, meningiomas, and a variety of metastatic cancers, 5-ALA seems to be a promising tool for enhancing intraoperative identification of neoplastic tissue and optimizing the extent of resection.

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Section: -Ala Fluorescence In Primary Brain Tumorsmentioning

confidence: 99%

Use of fluorescence to guide resection or biopsy of primary brain tumors and brain metastases

Marbacher

Klinger

Schwyzer

et al. 2014

FOC

141

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“…Though the exact mechanisms of 5-ALA penetration of glioma are still uncertain, it appears that bulk flow of 5-ALA across the leaky GBM vasculature and active transport at the blood-brain and blood-CSF interfaces contribute to 5-ALA-induced fluorescence in both in vitro and in vivo tumor models [16, 19-22]. In a randomized Phase III study, Stummer et al demonstrated that more extensive GBM resection and higher PFS rates were achievable with 5-ALA FGS compared to conventional resection, leading to multiple follow-up studies on the technique [4-5, 23-32]. …”

Section: Introductionmentioning

confidence: 99%

Semi-Automated Volumetric and Morphological Assessment of Glioblastoma Resection with Fluorescence-Guided Surgery

et al. 2015

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Purpose Glioblastoma (GBM) neurosurgical resection relies on contrast-enhanced MRI-based neuronavigation. However, it is well-known that infiltrating tumor extends beyond contrast enhancement. Fluorescence-guided surgery (FGS) using 5-aminolevulinic acid (5-ALA) was evaluated to improve extent of resection (EOR) of GBMs. Pre-operative morphological tumor metrics were also assessed. Procedures Thirty patients from a Phase II trial evaluating 5-ALA FGS in newly diagnosed GBM were assessed. Tumors were segmented pre-operatively to assess morphological features as well as post-operatively to evaluate EOR and residual tumor volume (RTV). Results Median EOR and RTV were 94.3% and 0.821 cm3, respectively. Pre-operative surface area to volume ratio and RTV were significantly associated with overall survival, even when controlling for the known survival confounders. Conclusions This study supports claims that 5-ALA FGS is helpful at decreasing tumor burden and prolonging survival in GBM. Moreover, morphological indices are shown to impact both resection and patient survival.

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“…A 2012 review by Sanai found five studies which used volumetric imaging to compare pre and postoperative MRIs for the EOR of contrast enhancement for patients undergoing surgical treatment of primary GBM. Three of these studies showed a survival advantage of between 2-8 months for patients undergoing complete resections compared to subtotal resections [18]. He also found that seventeen out of twenty eight nonvolumetric studies also found a survival advantage for extent of resection on univariate analysis [18].…”

Section: Literature Review Of Positive Prognostic Effect For Extent Omentioning

confidence: 98%

Techniques to Improve the Extent of Brain Tumor Resection — Awake Speech and Motor Mapping, and Intraoperative MRI

Vitaz¹

2015

Molecular Considerations and Evolving Surgical Management Issues in the Treatment of Patients With a Brain Tumor

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Emerging operative strategies in neurosurgical oncology

Cited by 28 publications

References 114 publications

Use of fluorescence to guide resection or biopsy of primary brain tumors and brain metastases

Use of fluorescence to guide resection or biopsy of primary brain tumors and brain metastases

Semi-Automated Volumetric and Morphological Assessment of Glioblastoma Resection with Fluorescence-Guided Surgery

Techniques to Improve the Extent of Brain Tumor Resection — Awake Speech and Motor Mapping, and Intraoperative MRI

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