Hybrid fluorescein-guided surgery for pituitary adenoma resection: a pilot study

Abstract

OBJECTIVEThe authors conducted a pilot study on hybrid fluorescein-guided surgery for pituitary adenoma resection and herein describe the feasibility and safety of this technique.METHODSIn this pilot study, the authors included all consecutive patients presenting with pituitary adenomas, functioning and nonfunctioning. They performed a hybrid fluorescein-guided surgical technique for tumor resection. An endonasal endoscopic approach was used; after exposure of the rostrum of the sphenoid sinus, they administered a bolus of 8 mg/kg of fluorescein sodium (FNa) intravenously, and during resection, they alternated between endoscopic and microscopic techniques to guide the resection under a YELLOW 560 filter.RESULTSThe study included 15 patients, 7 men (47%) and 8 women (53%). Of the pituitary adenomas, 7 (46%) were nonfunctioning, 6 (40%) were GH secreting, 1 (7%) was prolactin secreting, and 1 (7%) was ACTH secreting. There were no FNa-related complications (anaphylactic reactions); yellowish staining of urine, skin, and mucosa was seen in all patients and resolved in a maximum time of 24 hours. After color spectrophotometric analysis, the authors identified a statistical difference in fluorescence among tumor, gland, and scar tissue (p = 0.01).CONCLUSIONSThis is the first study of its kind to describe the feasibility and safety of using FNa to guide the resection of pituitary adenomas. The authors found this technique to be safe and feasible. It may be used to obtain better surgical results, especially for hormone-producing and recurring tumors, as well as for reducing the learning curve in pituitary adenoma surgery.

Fluorescence-guided detection of pituitary neuroendocrine tumor (PitNET) tissue during endoscopic transsphenoidal surgery available agents, their potential, and technical aspects

“…The light emitted from this yellow-green fluorophore is visible to the naked eye. FNa is used in the medical setting in ophthalmology for diagnostic use and in neurosurgery during the resection of high grade gliomas, metastatic lesions, treatment of cerebral aneurysms, and vascular malformations [ 11 , 12 ]. FNa accumulation is the result of disturbed vascular permeability due to a disrupted blood–brain barrier [ 1 ].…”

“…Six tumors were resected totally, three sub-totally and six partially. Functioning adenomas were found to have the highest intensity of fluorescence (p = 0.003) [ 12 ].…”

Fluorophores Use in Pituitary Surgery: A Pharmacokinetics and Pharmacodynamics Appraisal

“…The second experience with fluorescein was only recently published by Romano-Feinholz et al, employing a technique involving a hybrid endoscopic-microscopic surgical resection [ 33 ]. In particular, they performed a standard endoscopic approach and checked differences in pituitary tissues with the aid of a fluorescein-detecting microscope at the time of lesion visualization.…”

Effect of 5-Aminolevulinic Acid and Sodium Fluorescein on the Extent of Resection in High-Grade Gliomas and Brain Metastasis

“…The said advantages include (i) being a cheaper alternative (approximately 1/20 the price of 5-ALA); (ii) it has no side effects; (iii) it is easier to use in clinical practice as it is given intravenously at the beginning of an operation and does not require darkening of the operating room during an operation; and lastly, (iv) SF is absorbed nonspecifically where the blood-brain barrier is disrupted, which might make it much more useful for other types of tumors as well [27]. Recent studies, primarily case series with low sample sizes, indicate potential benefits of SF in the surgery of brain metastases [28], meningiomas [29], lymphomas [30,31], pituitary [32,33], pediatric brain stem [34,35], and spinal cord tumors [36,37].…”