Microscopic navigation-guided fence post technique for maximal tumor resection during glioma surgery

Abstract BACKGROUND: The beneficial role of the extent of resection (EOR) in glioma surgery in correlation to increased survival remains controversial. However, common literature favors maximum EOR with preservation of neurological function, which is shown to be associated with a significantly improved outcome. OBJECTIVE: In order to obtain a maximum EOR, it was examined whether high-field intraoperative magnetic resonance imaging (iMRI) combined with multimodal navigation contributes to a significantly improved EOR in glioma surgery. METHODS: Two hundred ninety-three glioma patients underwent craniotomy and tumor resection with the aid of intraoperative 1.5 T MRI and integrated multimodal navigation. In cases of remnant tumor, an update of navigation was performed with intraoperative images. Tumor volume was quantified pre- and intraoperatively by segmentation of T2 abnormality in low-grade and contrast enhancement in high-grade gliomas. RESULTS: In 25.9% of all cases examined, additional tumor mass was removed as a result of iMRI. This led to complete tumor resection in 20 cases, increasing the rate of gross-total removal from 31.7% to 38.6%. In 56 patients, additional but incomplete resection was performed because of the close location to eloquent brain areas. Volumetric analysis showed a significantly (P < .01) reduced mean percentage of tumor volume following additional further resection after iMRI from 33.5% ± 25.1% to 14.7% ± 23.3% (World Health Organization [WHO] grade I, 32.8% ± 21.9% to 6.1% ± 18.8%; WHO grade II, 24.4% ± 25.1% to 10.8% ± 11.0%; WHO grade III, 35.1% ± 27.3% to 24.8% ± 26.3%; WHO grade IV, 34.2% ± 23.7% to 1.2% ± 16.2%). CONCLUSION: MRI in conjunction with multimodal navigation and an intraoperative updating procedure enlarges tumor-volume reduction in glioma surgery significantly without higher postoperative morbidity.

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FLGS-01. Development of novel topical fluorescent probe for intraoperative rapid detection of glioma

Neuro-Oncology ◽

10.1093/neuonc/noab196.905 ◽

2021 ◽

Vol 23 (Supplement_6) ◽

pp. vi225-vi226

Author(s):

Shota Tanaka ◽

Yosuke Kitagawa ◽

Mako Kamiya ◽

Takenori Shimizu ◽

Yasuteru Urano ◽

...

Keyword(s):

Malignant Glioma ◽

Fluorescent Probe ◽

Rapid Detection ◽

Aminolevulinic Acid ◽

Characteristic Curve ◽

Screening Method ◽

Tumor Resection ◽

Phase Iii ◽

Glioma Surgery ◽

Two Dimensional Gel Electrophoresis

Abstract PURPOSE Fluorescence imaging is an important surgical adjunct in malignant glioma surgery. 5-aminolevulinic acid (5-ALA) has been proven effective for radical tumor resection and extended progression-free survival in a phase III randomized trial and therefore integrated into surgery for malignant glioma. Importantly, however, some limitations still exist in its use, which include false positivity and false negativity as well as inability of re-administration. In this study, we aimed to develop a novel, spray-type fluorescent probe using hydroxymethyl rhodamine green (HMRG) as a fluorescent scaffold. METHODS We have previously established a fluorescent probe library comprised of more than 320 kinds of HMRG probes. They have HMRG as a fluorescent scaffold with various types of dipeptides attached to it. Primary probe screening was performed using the homogenized tumor samples from patients with glioblastoma operated at our institution. Secondary screening followed using the selected probes and fresh tumor samples obtained from patients with glioblastoma operated from 2016 until 2018. Diced electrophoresis gel (DEG) assay, two-dimensional gel electrophoresis followed by a multi-well plate-based fluorometric assay, was performed to identify responsible enzymes for the selected probe. Further experiments with inhibitors, real-time PCR, immunohistochemistry, and western blotting were performed for confirmation. RESULTS Proline-arginine-HMRG (PR-HMRG) was selected as a candidate probe based upon the above two-step screenings. It achieved 79.4% accuracy in receiver operating characteristic curve analysis. Calpain-1 was found to be responsible to cleave PR-HMRG probe by DEG-proteome analysis. Calpain-1 protein was highly expressed in tumor tissues which reacted to PR-HMRG probe. CONCLUSIONS Our innovative screening method was able to find PR-HMRG as a novel fluorescent probe effective for rapid detection of glioblastoma. A preclinical study is planned to assess the efficacy and safety of the selected probe.

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Letter to the Editor Regarding “The Diagnostic Properties of Intraoperative Ultrasound in Glioma Surgery and Factors Associated with Gross Total Tumor Resection”

World Neurosurgery ◽

10.1016/j.wneu.2018.12.179 ◽

2019 ◽

Vol 125 ◽

pp. 553-554

Author(s):

Francesco Prada ◽

Ignazio G. Vetrano ◽

Massimiliano DelBene ◽

Giovanni Mauri ◽

Luca M. Sconfienza ◽

...

Keyword(s):

Tumor Resection ◽

Intraoperative Ultrasound ◽

Glioma Surgery ◽

Factors Associated ◽

Letter To The Editor ◽

Diagnostic Properties

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A novel threshold criterion in transcranial motor evoked potentials during surgery for gliomas close to the motor pathway

Journal of Neurosurgery ◽

10.3171/2015.8.jns151439 ◽

2016 ◽

Vol 125 (4) ◽

pp. 795-802 ◽

Cited By ~ 10

Author(s):

Tammam Abboud ◽

Miriam Schaper ◽

Lasse Dührsen ◽

Cindy Schwarz ◽

Nils Ole Schmidt ◽

...

Keyword(s):

Evoked Potentials ◽

Motor Evoked Potentials ◽

Tumor Resection ◽

Threshold Level ◽

Neurological Deterioration ◽

Motor Deficit ◽

Percentage Increase ◽

Glioma Surgery ◽

Leg Muscles ◽

Threshold Criterion

OBJECTIVE Warning criteria for monitoring of motor evoked potentials (MEP) after direct cortical stimulation during surgery for supratentorial tumors have been well described. However, little is known about the value of MEP after transcranial electrical stimulation (TES) in predicting postoperative motor deficit when monitoring threshold level. The authors aimed to evaluate the feasibility and value of this method in glioma surgery by using a new approach for interpreting changes in threshold level involving contra- and ipsilateral MEP. METHODS Between November 2013 and December 2014, 93 patients underwent TES-MEP monitoring during resection of gliomas located close to central motor pathways but not involving the primary motor cortex. The MEP were elicited by transcranial repetitive anodal train stimulation. Bilateral MEP were continuously evaluated to assess percentage increase of threshold level (minimum voltage needed to evoke a stable motor response from each of the muscles being monitored) from the baseline set before dural opening. An increase in threshold level on the contralateral side (facial, arm, or leg muscles contralateral to the affected hemisphere) of more than 20% beyond the percentage increase on the ipsilateral side (facial, arm, or leg muscles ipsilateral to the affected hemisphere) was considered a significant alteration. Recorded alterations were subsequently correlated with postoperative neurological deterioration and MRI findings. RESULTS TES-MEP could be elicited in all patients, including those with recurrent glioma (31 patients) and preoperative paresis (20 patients). Five of 73 patients without preoperative paresis showed a significant increase in threshold level, and all of them developed new paresis postoperatively (transient in 4 patients and permanent in 1 patient). Eight of 20 patients with preoperative paresis showed a significant increase in threshold level, and all of them developed postoperative neurological deterioration (transient in 4 patients and permanent in 4 patients). In 80 patients no significant change in threshold level was detected, and none of them showed postoperative neurological deterioration. The specificity and sensitivity in this series were estimated at 100%. Postoperative MRI revealed gross-total tumor resection in 56 of 82 patients (68%) in whom complete tumor resection was attainable; territorial ischemia was detected in 4 patients. CONCLUSIONS The novel threshold criterion has made TES-MEP a useful method for predicting postoperative motor deficit in patients who undergo glioma surgery, and has been feasible in patients with preoperative paresis as well as in patients with recurrent glioma. Including contra- and ipsilateral changes in threshold level has led to a high sensitivity and specificity.

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Intraoperative perception and estimates on extent of resection during awake glioma surgery: overcoming the learning curve

Journal of Neurosurgery ◽

10.3171/2017.1.jns161811 ◽

2018 ◽

Vol 128 (5) ◽

pp. 1410-1418 ◽

Cited By ~ 9

Author(s):

Darryl Lau ◽

Shawn L. Hervey-Jumper ◽

Seunggu J. Han ◽

Mitchel S. Berger

Keyword(s):

Learning Curve ◽

Tumor Resection ◽

Extent Of Resection ◽

Neurological Deficits ◽

Language Outcomes ◽

Glioma Surgery ◽

Ample Evidence ◽

Postoperative Mri ◽

Significant Difference ◽

Surgeon Experience

OBJECTIVEThere is ample evidence that extent of resection (EOR) is associated with improved outcomes for glioma surgery. However, it is often difficult to accurately estimate EOR intraoperatively, and surgeon accuracy has yet to be reviewed. In this study, the authors quantitatively assessed the accuracy of intraoperative perception of EOR during awake craniotomy for tumor resection.METHODSA single-surgeon experience of performing awake craniotomies for tumor resection over a 17-year period was examined. Retrospective review of operative reports for quantitative estimation of EOR was recorded. Definitive EOR was based on postoperative MRI. Analysis of accuracy of EOR estimation was examined both as a general outcome (gross-total resection [GTR] or subtotal resection [STR]), and quantitatively (5% within EOR on postoperative MRI). Patient demographics, tumor characteristics, and surgeon experience were examined. The effects of accuracy on motor and language outcomes were assessed.RESULTSA total of 451 patients were included in the study. Overall accuracy of intraoperative perception of whether GTR or STR was achieved was 79.6%, and overall accuracy of quantitative perception of resection (within 5% of postoperative MRI) was 81.4%. There was a significant difference (p = 0.049) in accuracy for gross perception over the 17-year period, with improvement over the later years: 1997–2000 (72.6%), 2001–2004 (78.5%), 2005–2008 (80.7%), and 2009–2013 (84.4%). Similarly, there was a significant improvement (p = 0.015) in accuracy of quantitative perception of EOR over the 17-year period: 1997–2000 (72.2%), 2001–2004 (69.8%), 2005–2008 (84.8%), and 2009–2013 (93.4%). This improvement in accuracy is demonstrated by the significantly higher odds of correctly estimating quantitative EOR in the later years of the series on multivariate logistic regression. Insular tumors were associated with the highest accuracy of gross perception (89.3%; p = 0.034), but lowest accuracy of quantitative perception (61.1% correct; p < 0.001) compared with tumors in other locations. Even after adjusting for surgeon experience, this particular trend for insular tumors remained true. The absence of 1p19q co-deletion was associated with higher quantitative perception accuracy (96.9% vs 81.5%; p = 0.051). Tumor grade, recurrence, diagnosis, and isocitrate dehydrogenase-1 (IDH-1) status were not associated with accurate perception of EOR. Overall, new neurological deficits occurred in 8.4% of cases, and 42.1% of those new neurological deficits persisted after the 3-month follow-up. Correct quantitative perception was associated with lower postoperative motor deficits (2.4%) compared with incorrect perceptions (8.0%; p = 0.029). There were no detectable differences in language outcomes based on perception of EOR.CONCLUSIONSThe findings from this study suggest that there is a learning curve associated with the ability to accurately assess intraoperative EOR during glioma surgery, and it may take more than a decade to be truly proficient. Understanding the factors associated with this ability to accurately assess EOR will provide safer surgeries while maximizing tumor resection.

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Usefulness of Intraoperative Ultra Low-field Magnetic Resonance Imaging in Glioma Surgery

Operative Neurosurgery ◽

10.1227/01.neu.0000313624.77452.3c ◽

2008 ◽

Vol 63 (suppl_4) ◽

pp. ONS257-ONS267 ◽

Cited By ~ 42

Author(s):

Christian Senft ◽

Volker Seifert ◽

Elvis Hermann ◽

Kea Franz ◽

Thomas Gasser

Keyword(s):

Magnetic Resonance Imaging ◽

Magnetic Resonance ◽

Tumor Resection ◽

Extent Of Resection ◽

Resonance Imaging ◽

Complete Tumor Resection ◽

Glioma Surgery ◽

Low Field ◽

Low Field Mri ◽

Complete Tumor

Abstract Objective: The aim of this study was to demonstrate the usefulness of a mobile, intraoperative 0.15-T magnetic resonance imaging (MRI) scanner in glioma surgery. Methods: We analyzed our prospectively collected database of patients with glial tumors who underwent tumor resection with the use of an intraoperative ultra low-field MRI scanner (PoleStar N-20; Odin Medical Technologies, Yokneam, Israel/Medtronic, Louisville, CO). Sixty-three patients with World Health Organization Grade II to IV tumors were included in the study. All patients were subjected to postoperative 1.5-T imaging to confirm the extent of resection. Results: Intraoperative image quality was sufficient for navigation and resection control in both high-and low-grade tumors. Primarily enhancing tumors were best detected on T1-weighted imaging, whereas fluid-attenuated inversion recovery sequences proved best for nonenhancing tumors. Intraoperative resection control led to further tumor resection in 12 (28.6%) of 42 patients with contrast-enhancing tumors and in 10(47.6%) of 21 patients with noncontrast-enhancing tumors. In contrast-enhancing tumors, further resection led to an increased rate of complete tumor resection (71.2 versus 52.4%), and the surgical goal of gross total removal or subtotal resection was achieved in all cases (100.0%). In patients with noncontrast-enhancing tumors, the surgical goal was achieved in 19 (90.5%) of 21 cases, as intraoperative MRI findings were inconsistent with postoperative high-field imaging in 2 cases. Conclusion: The use of the PoleStar N-20 intraoperative ultra low-field MRI scanner helps to evaluate the extent of resection in glioma surgery. Further tumor resection after intraoperative scanning leads to an increased rate of complete tumor resection, especially in patients with contrast-enhancing tumors. However, in noncontrast-enhancing tumors, the intraoperative visualization of a complete resection seems less specific, when compared with postoperative 1.5-T MRI.

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New Hope in Brain Glioma Surgery: The Role of Intraoperative Ultrasound. A Review

Brain Sciences ◽

10.3390/brainsci8110202 ◽

2018 ◽

Vol 8 (11) ◽

pp. 202 ◽

Cited By ~ 6

Author(s):

Maria Pino ◽

Alessia Imperato ◽

Irene Musca ◽

Rosario Maugeri ◽

Giuseppe Giammalva ◽

...

Keyword(s):

Brain Tumor ◽

Brain Tumors ◽

Low Cost ◽

Tumor Resection ◽

Intraoperative Ultrasound ◽

Tumor Surgery ◽

Brain Tumor Surgery ◽

Glioma Surgery ◽

Pubmed Database

Maximal safe resection represents the gold standard for surgery of malignant brain tumors. As regards gross-total resection, accurate localization and precise delineation of the tumor margins are required. Intraoperative diagnostic imaging (Intra-Operative Magnetic Resonance-IOMR, Intra-Operative Computed Tomography-IOCT, Intra-Operative Ultrasound-IOUS) and dyes (fluorescence) have become relevant in brain tumor surgery, allowing for a more radical and safer tumor resection. IOUS guidance for brain tumor surgery is accurate in distinguishing tumor from normal parenchyma, and it allows a real-time intraoperative visualization. We aim to evaluate the role of IOUS in gliomas surgery and to outline specific strategies to maximize its efficacy. We performed a literature research through the Pubmed database by selecting each article which was focused on the use of IOUS in brain tumor surgery, and in particular in glioma surgery, published in the last 15 years (from 2003 to 2018). We selected 39 papers concerning the use of IOUS in brain tumor surgery, including gliomas. IOUS exerts a notable attraction due to its low cost, minimal interruption of the operational flow, and lack of radiation exposure. Our literature review shows that increasing the use of ultrasound in brain tumors allows more radical resections, thus giving rise to increases in survival.

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Intraoperative tumor segmentation and volume measurement in MRI-guided glioma surgery for tumor resection rate control1

Academic Radiology ◽

10.1016/j.acra.2004.11.009 ◽

2005 ◽

Vol 12 (1) ◽

pp. 116-122 ◽

Cited By ~ 10

Author(s):

Nobuhiko Hata ◽

Yoshihiro Muragaki ◽

Takashi Inomata ◽

Takashi Maruyama ◽

Hiroshi Iseki ◽

...

Keyword(s):

Tumor Resection ◽

Volume Measurement ◽

Tumor Segmentation ◽

Resection Rate ◽

Glioma Surgery ◽

Mri Guided

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5-Aminolevulinic Acid Fluorescence-Guided Resection of Intramedullary Ependymoma: Report of 9 Cases

Operative Neurosurgery ◽

10.1227/neu.0b013e31827bc7a3 ◽

2012 ◽

Vol 72 (2) ◽

pp. ons159-ons168 ◽

Cited By ~ 12

Author(s):

Tomoo Inoue ◽

Toshiki Endo ◽

Kenichi Nagamatsu ◽

Mika Watanabe ◽

Teiji Tominaga

Keyword(s):

Spinal Cord ◽

Aminolevulinic Acid ◽

Tumor Resection ◽

Extent Of Resection ◽

Labeling Index ◽

World Health ◽

Histopathological Diagnosis ◽

Glioma Surgery ◽

Ki 67 ◽

Grade Ii

Abstract BACKGROUND: Resection guided by 5-aminolevulinic acid (5-ALA) fluorescence has proved to be useful in intracranial glioma surgery. However, the effects of 5-ALA on spinal cord tumors remain unknown. OBJECTIVE: To evaluate the usefulness of 5-ALA fluorescence-guided resection of intramedullary ependymoma for achieving maximum tumor resection. METHODS: This study included 10 patients who underwent surgical resection of an intramedullary ependymoma. Nine patients were orally administered 5-ALA (20 mg/kg) 2 hours before the induction of anesthesia. 5-ALA fluorescence was visualized with an operating microscope. Tumors were removed in a standardized manner with electro-physiological monitoring. The extent of resection was evaluated on the basis of intra-operative findings and postoperative magnetic resonance imaging. Histopathological diagnosis was established according to World Health Organization 2007 criteria. Cell proliferation was assessed by Ki-67 labeling index. RESULTS: 5-ALA fluorescence was positive in 7 patients (6 grade II and 1 grade III) and negative in 2 patients (grade II). Intraoperative findings were dichotomized: Tumors covered by the cyst were easily separated from the normal parenchyma, whereas tumors without the cyst appeared to be continuous to the spinal cord. In these cases, 5-ALA fluorescence was especially valuable in delineating the ventral and cranial and caudal margins. Ki-67 labeling index was significantly higher in 5-ALA-positive cases compared with 5-ALA-negative cases. All patients improved neurologically or stabilized after surgery. CONCLUSION: 5-ALA fluorescence was useful for detecting tumor margins during surgery for intramedullary ependymoma. When combined with electrophysiological monitoring, fluorescence-guided resection could help to achieve maximum tumor resection safely.

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