Fluorescence-Guided Resection of Spinal Metastases of Malignant Glioma: Report of 2 Cases

Rapp, Marion; Klingenhöfer, Mark; Felsberg, Jörg; Steiger, Hans Jakob; Stummer, Walter; Sabel, Michael

doi:10.1055/s-0032-1309068

Cited by 10 publications

(12 citation statements)

References 8 publications

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“…The aim was to evaluate in which spinal tumor entities 5-ALA accumulates and thereby improves visualization of tumor tissue and potentially serves as a helpful tool for surgery. Though 5-ALA has been employed for the visualization of various tumors, there are only a few reports on 5-ALA fluorescence in spinal intradural pathologies [3,9,20,21].…”

Section: Discussionmentioning

confidence: 99%

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The impact of fluorescence guidance on spinal intradural tumour surgery

Eicker

Floeth²,

Kamp

et al. 2013

Eur Spine J

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Purpose 5-Aminolevulinic acid (5-ALA)-based fluorescence-guided surgery was shown to be beneficial for cerebral malignant gliomas. Extension of this technique for resection of meningiomas and cerebral metastasis has been recently evaluated. Aim of the present study is to evaluate the impact of fluorescence-guided surgery in spinal tumor surgery. Methods Twenty-six patients with intradural spinal tumors were included in the study. 5-ALA was administered orally prior to the induction of anesthesia. Intraoperative, 440 nm fluorescence was applied after exploration of the tumor and, if positive, periodically during and at the end of resection to detect tumor-infiltrated sites. Results Tumors of WHO grade III and IV were found in five patients. In detail intra-or perimedullary metastasis of malignant cerebral gliomas was found including glioblastoma WHO grade IV (n = 2), anaplastic astrocytoma WHO grade III (n = 1), anaplastic oligoastrocytoma WHO grade III (n = 1). In addition, one patient suffered from a spinal drop metastasis of a cerebellar medulloblastoma WHO grade IV. Tumors of WHO grade I were diagnosed in 18 patients: Eight cases of meningioma (two recurrences), six cases of neurinoma, one neurofibroma, two ependymoma and one plexus papilloma. At least, benign pathologies were histologically proven in three patients. All four spinal metastasis of malignant glioma (100 %), seven of eight meningiomas (87.5 %) and one of two ependymoma (50 %) were found to be ALA-positive. Conclusion The present study demonstrates that spinal intramedullary gliomas and the majority of spinal intradural meningiomas are 5-ALA positive. As a surgical consequence, especially in intramedullary gliomas, the use of 5-ALA fluorescence seems to be beneficial.

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Section: Discussionmentioning

confidence: 99%

“…Extension of this technique to spinal intradural pathologies is documented in only four case reports [3,9,20,21].…”

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confidence: 99%

The impact of fluorescence guidance on spinal intradural tumour surgery

Eicker

Floeth²,

Kamp

et al. 2013

Eur Spine J

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“…2,4,14,15,44 Recently, 5-ALA was applied for the intraoperative visualization of spinal tumors in single cases and two small studies. 5,7,12,23,28,33 Protoporphyrin IX fluorescence was observed particularly in ependymomas, meningiomas, and malignant gliomas. Note, however, that a systematic analysis of the value of 5-ALA for intraoperative visualization of different intradural as well as extradural spinal tumors in a large patient series is still missing.…”

Section: Fluorescence-guided Procedures With 5-ala In Neurosurgerymentioning

confidence: 99%

“…So far, PpIX fluorescence has been observed in a few cases of ependymomas, meningiomas, and malignant gliomas. 7,12,23,28,33 However, it remains unclear which specific histopathological spinal tumor entities can be visualized with 5-ALA-induced PpIX fluorescence.…”

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confidence: 99%

Analysis of 5-aminolevulinic acid–induced fluorescence in 55 different spinal tumors

Millesi

Kiesel

Wöehrer

et al. 2014

FOC

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Object Subtotal resection (STR) of spinal tumors can result in tumor recurrence. Currently, no clinically reliable marker is available for intraoperative visualization of spinal tumor tissue. Protoporphyrin IX (PpIX) fluorescence induced by 5-aminolevulinic acid (5-ALA) is capable of visualizing malignant gliomas. Fluorescence-guided resections of malignant cerebral gliomas using 5-ALA have resulted in an increased rate of complete tumor removal. Recently, the application of 5-ALA has also been described in the first cases of spinal tumors. Therefore, the aim of this observational study was to systematically investigate 5-ALA–induced fluorescence characteristics in different spinal tumor entities. Methods Three hours before the induction of anesthesia, 5-ALA was administered to patients with different intra- and extradural spinal tumors. In all patients a neurosurgical resection or biopsy of the spinal tumor was performed under conventional white-light microscopy. During each surgery, the presence of PpIX fluorescence was additionally assessed using a modified neurosurgical microscope. At the end of an assumed gross-total resection (GTR) under white-light microscopy, a final inspection of the surgical cavity of fluorescing intramedullary tumors was performed to look for any remaining fluorescing foci. Histopathological tumor diagnosis was established according to the current WHO classification. Results Fifty-two patients with 55 spinal tumors were included in this study. Resection was performed in 50 of 55 cases, whereas 5 of 55 cases underwent biopsy. Gross-total resection was achieved in 37 cases, STR in 5, and partial resection in 8 cases. Protoporphyrin IX fluorescence was visible in 30 (55%) of 55 cases, but not in 25 (45%) of 55 cases. Positive PpIX fluorescence was mainly detected in ependymomas (12 of 12), meningiomas (12 of 12), hemangiopericytomas (3 of 3), and in drop metastases of primary CNS tumors (2 of 2). In contrast, none of the neurinomas (8 of 8), carcinoma metastases (5 of 5), and primary spinal gliomas (3 of 3; 1 pilocytic astrocytoma, 1 WHO Grade II astrocytoma, 1 WHO Grade III anaplastic oligoastrocytoma) revealed PpIX fluorescence. It is notable that residual fluorescing tumor foci were detected and subsequently resected in 4 of 8 intramedullary ependymomas despite assumed GTR under white-light microscopy. Conclusions In this study, 5-ALA–PpIX fluorescence was observed in spinal tumors, especially ependymomas, meningiomas, hemangiopericytomas, and drop metastases of primary CNS tumors. In cases of intramedullary tumors, 5-ALA–induced PpIX fluorescence is a useful tool for the detection of potential residual tumor foci.

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“…26 Case reports describing positive tumour fluorescence from ALA also exist for cerebral lymphoma, 32 hemangioblastoma cysts, 33 demyelinating brain disease, 34 medulloblastoma, 35 metastasis, 30 vasculitis, 20 spinal metastasis, 36 peritumour inflammatory cells and infiltrating astrocytes. 25 The clinical utility of PpIX fluorescence in these conditions is yet to be established.…”

Section: Other Tumour Typesmentioning

confidence: 99%