Fluorescein-Guided Surgery for Pediatric Brainstem Gliomas: Preliminary Study and Technical Notes

Abstract

Brainstem gliomas (BsG) account for 10 to 15% of pediatric brain tumors. Surgery is the preferred treatment for focal and exophytic lesions. Sodium fluorescein has been proven safe and effective in resection of malignant brain tumors. The objective was to o analyze the safety and effectiveness of this approach, to evaluate intraoperative fluorescein imaging, and to measure the safety of chosen dose for pediatric patients. Twelve cases were enrolled between March 2014 and September 2016 in Beijing Tiantan Hospital. All of the patients received 2.5 mg/kg of sodium fluorescein before opening the dura; the intraoperative fluorescence enhancement was observed, and the degree of satisfaction and consistency with the neuronavigation were evaluated. With a mean age of 7.5 years, there were eight cases located within the pontine, three in the medullary oblongata, and one in the tectal plate. Histological results were astrocytoma, glioblastoma, oligodendroglioma, and pilocytic astrocytoma. Under the fluorescein module of the microscope, the tumors were recognizable enough to help surgeons to discriminate the lesion from non-fluorescent tissue, with a consistency of 83% with the neuronavigation. Total removal was accomplished in nine cases, while the mean percentage of resection of the other cases was 93.7%. The Karnofsky performance score (KPS) showed no significant differences between pre-operation and discharge, but there was a difference between pre-operation and 6-month follow-up. The fluorescein-guided surgery is useful for demarcating the tumor margin and works well with other navigation and monitoring devices. A safe dose of sodium fluorescein (2.5 mg/kg) was proven effective for children.

Machine learning assisted intraoperative assessment of brain tumor margins using HRMAS NMR spectroscopy

“…Providing feedback on left-over malign tissue during surgery can help surgeons delineate more precisely the limits of a tumor infiltration, especially after a macroscopically complete excision. Several innovative techniques based on optical spectrometry [4][5][6][7][8][9][10][11][12][13][14][15][16] or mass spectrometry [17][18][19][20][21][22][23][24][25] are now proposed to help surgeons to evaluate the margins of resection and possibly to amplify the surgical procedure. Metabolic profiling of a biopsy sample by High Resolution Magic Angle Spinning Nuclear Magnetic Resonance (HRMAS NMR) spectroscopy is a recent novel technique for efficiently distinguishing malign and healthy tissues in excision cavity during surgery.…”

Machine Learning Assisted Intraoperative Assessment of Brain Tumor Margins Using HRMAS NMR Spectroscopy

“…Providing feedback on left-over malign tissue during surgery can help surgeons delineate more precisely the limits of a tumor infiltration, especially after a macroscopically complete excision. Several innovative techniques based on optical spectrometry [5,6,11,14,15,17,20,24,25,29,34,36,41] or mass spectrometry [2–4, 7, 8, 13, 28, 31, 32] are now proposed to help surgeons to evaluate the margins of resection and possibly to amplify the surgical procedure. Metabolic profiling of a biopsy sample by High Resolution Magic Angle Spinning Nuclear Magnetic Resonance (HRMAS NMR) spectroscopy is a recent novel technique for efficiently distinguishing malign and healthy tissues in excision cavity during surgery.…”

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

“…[44,50,62,82] Unlike supratentorial malignant tumors, for which the extent of tumor resection (EOR) has a predictive value for outcome, [11,49,75,76] the goal for BSG will always be maximal safe resection, seeking a balance between GTR and postoperative neurological function. [87] We attained a GTR in 3 (37%) cases, NTR in 3 cases (37%), and STR in 2 cases (25%). In two of our cases, despite solid fluorescent tissue still visible in the surgical field, we needed to abort surgery due to abnormalities on neurophysiological monitoring.…”

“…[12,13,48,57] Although there are no sanctioned radiological guidelines for the diagnosis of a DIPG, [22] in the current series, we relied on the classic features [18,88] While there are proponents of surgery for diffuse BSGs, [37,43,80] surgical resection of these lesions carries a high morbidity and mortality, and radiation therapy is generally considered the primary therapy. [30,59,87] Conversely, the therapeutic goal of focal BSGs is safe and total surgical removal. [14,30,42,53] In most cases, a well-defined interface between the tumor and neural tissue indicates a GTR or STR resulting in a favorable prognosis.…”