Navigable Intraoperative Ultrasound and Fluorescence-Guided Resections Are Complementary in Resection Control of Malignant Gliomas: One Size Does Not Fit All

Abstract INTRODUCTION Intraoperative ultrasound (iUS) is a promising tool for glioma surgery. Navigated 3-D (n3D) iUS has many benefits over standard 2-D iUS. METHODS This was a retrospective comparative cohort study using propensity score matching (PSM). 500 consecutive histologically confirmed gliomas were divided into 2 cohorts – 2DiUS - Cohort A; and n3DiUS -Cohort B. PSM was used to account for known confounders (250 in each group; 1:1 matching). Gross total resection rates (based on iUS findings as well as postoperative MR) and perioperative morbidity were analyzed across the groups as were factors influencing these outcomes (using univariate as well as multivariate regression models). RESULTS Overall, the majority of the patients were adults (94%), males (71%) with hemispheric tumors (96%). 35% had tumors close to eloquent regions and 23% had received some prior treatment. The majority were high-grade gliomas (85%). 2D iUS was employed mainly for localization (80%) whereas n3D was used predominantly for resection control (84%) [p < 0.001]. GTR rate was higher in the n3D cohort (55.2% vs 38.4% in 2D; p = 0.001). The odds of having a complete resection in the n3D cohort was twice that of the 2D. Prior treatment, hemispheric location, and use of fluorescence were also significantly associated with higher GTR rates on univariate analysis. On multivariate analysis, all of these remained significant. There was no difference in the morbidity rates in the two cohorts. N3D iUS had a higher specificity and positive likelihood ratio in detecting tumor residue. CONCLUSION For hemispheric gliomas undergoing resective surgery, the use of navigated 3D ultrasound improves GTR rates, with no added morbidity. It is more likely to be used for resection control mode than is 2DUS and this is probably because n3DUS is more specific and likely to pick up tumor residues contributing to its better accuracy.

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Intraoperative ultrasound for resection control in transsphenoidal surgery

Experimental and Clinical Endocrinology & Diabetes ◽

10.1055/s-0033-1336612 ◽

2013 ◽

Vol 121 (03) ◽

Cited By ~ 1

Author(s):

J Rolfes ◽

WD Reinbold ◽

C Jaspers ◽

R Santen ◽

J Feldkamp ◽

...

Keyword(s):

Transsphenoidal Surgery ◽

Intraoperative Ultrasound ◽

Resection Control

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389 Advanced Intraoperative Navigated Ultrasound in Brain Tumor Surgery Lessons Learnt from a Personal Experience of 300 Cases

Neurosurgery ◽

10.1093/neuros/nyx417.389 ◽

2017 ◽

Vol 64 (CN_suppl_1) ◽

pp. 293-293

Author(s):

Aliasgar V Moiyadi

Keyword(s):

Brain Tumor ◽

Malignant Gliomas ◽

Tumor Resection ◽

3D Ultrasound ◽

Small Subset ◽

Neurosurgical Procedures ◽

Tumor Surgery ◽

Brain Tumor Surgery ◽

Resection Control ◽

Tumor Residue

Abstract INTRODUCTION Navigated 3D-ultrasound (nUS) is a powerful and multi-purpose adjunct during tumor resections. We review our cumulative results in a dedicated neuro-oncology service spanning a six year period, highlighting its role in glioma surgery. METHODS Since 2011 we have been used a navigated 3D ultrasound system for intraoperative image guidance during brain tumor surgery in 300 cases. A prospectively updated database was queried to retrieve demographic, clinico-radiological and pathological details. Specifically, we evaluated the utility of the IOUS in different setups and assessed its predictive accuracy and impact on extent of resection (EOR) as well as survival in gliomas. RESULTS >300 (204 males/96 females) brain tumors were operated [197 high grade gliomas, 28 LGG, 24 Meningiomas, and 51 other tumors]. Radical resection/debulking was intended in 270 (90%). In 30 (10%), only frameless biopsy was performed. The US was intended for resection control in 219 (73%) tumors, most of them being intrinsic gliomas. Intermediate scans prompted further resection in 101 cases (46%). A final resection control scan was performed in 176 cases (confirming complete excision in 99, and residual tumor which could not be further resected in 77). The nUS was a very useful tool in tumor surgery, providing a good diagnostic accuracy (85-90%) in predicting tumor residue. It also helped us improve the EOR in malignant gliomas as well as non-enhancing gliomas. In the subset of resectable tumors, the gross total resection rate was 88%. Further, in a small subset of malignant gliomas, we demonstrated that it helps extend tumor resection beyond the contrast enhancement zone. In GBMs, in a multivariate model, use of the nUS was an independent predictor of survival. CONCLUSION Considering the ease of use, widespread accessibility and low-cost nature, IOUS can be a potentially useful adjunct during a range of neurosurgical procedures, especially tumor resections.

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Usefulness of three-dimensional navigable intraoperative ultrasound in resection of brain tumors with a special emphasis on malignant gliomas

Acta Neurochirurgica ◽

10.1007/s00701-013-1881-z ◽

2013 ◽

Vol 155 (12) ◽

pp. 2217-2225 ◽

Cited By ~ 42

Author(s):

Aliasgar V. Moiyadi ◽

Prakash M. Shetty ◽

Abhishek Mahajan ◽

Amar Udare ◽

Epari Sridhar

Keyword(s):

Brain Tumors ◽

Malignant Gliomas ◽

Three Dimensional ◽

Intraoperative Ultrasound

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Intraoperative Fluorescence Is Useful but Not Always Sufficient in Contrast-Enhancing Malignant Gliomas

Indian Journal of Neurosurgery ◽

10.1055/s-0038-1639386 ◽

2018 ◽

Vol 07 (03) ◽

pp. 253-255

Author(s):

Aliasgar Moiyadi

Keyword(s):

Malignant Gliomas ◽

Tumor Resection ◽

Intraoperative Ultrasound ◽

Standard Of Care ◽

Tumor Type ◽

Resonance Imaging ◽

Knowing That ◽

Resection Status ◽

Magnetic Resonance Imaging Mri ◽

Optimal Tumor

AbstractFluorescence-guided resections have become standard of care for malignant gliomas. Strong fluorescence has been shown to correlate with solid enhancing tumor. However, with experience it has also been shown that visualized fluorescence may not identify the entire extent of the tumor. Knowing that malignant gliomas extend beyond the contrast-enhancing tumor seen on magnetic resonance imaging (MRI), reliance only on the fluorescence intraoperatively may not be enough. Intraoperative ultrasound is a readily available tool for real-time assessment of resection status, irrespective of the tumor type. We describe one such case in which after resecting all the visible fluorescing tumor component, we identified a significant component of nonfluorescing tumor, using intraoperative ultrasound that was further resected completely. This illustrates the need for multimodal intraoperative guidance for achieving optimal tumor resection in malignant gliomas.

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Navigated ultrasound-based image guidance during resection of gliomas: practical utility in intraoperative decision-making and outcomes

Neurosurgical FOCUS ◽

10.3171/2020.10.focus20550 ◽

2021 ◽

Vol 50 (1) ◽

pp. E14

Author(s):

Prakash Shetty ◽

Ujwal Yeole ◽

Vikas Singh ◽

Aliasgar Moiyadi

Keyword(s):

Decision Making ◽

Predictive Value ◽

Intraoperative Imaging ◽

False Negative ◽

Intraoperative Ultrasound ◽

Image Resolution ◽

Related Factors ◽

Resection Control ◽

Navigated Ultrasound ◽

Eloquent Location

OBJECTIVEIntraoperative imaging is increasingly being used for resection control in diffuse gliomas, in which the extent of resection (EOR) is important. Intraoperative ultrasound (iUS) has emerged as a highly effective tool in this context. Navigated ultrasound (NUS) combines the benefits of real-time imaging with the benefits of navigation guidance. In this study, the authors investigated the use of NUS as an intraoperative adjunct for resection control in gliomas.METHODSThe authors retrospectively analyzed 210 glioma patients who underwent surgery using NUS at their center. The analysis included intraoperative decision-making, diagnostic accuracy, and operative outcomes, particularly EOR and related factors influencing this.RESULTSUS-defined gross-total resection (GTR) was achieved in 57.6% of patients. Intermediate resection control scans were evaluable in 115 instances. These prompted a change in the operative decision in 42.5% of cases (the majority being further resection of unanticipated residual tumor). Eventual MRI-defined GTR rates were similar (58.6%), although the concordance between US and MRI was 81% (170/210 cases). There were 21 false positives and 19 false negatives with NUS, resulting in a sensitivity of 78%, specificity of 83%, positive predictive value of 77%, and negative predictive value of 84%. A large proportion of patients (13/19 patients, 68%) with false-negative results eventually had near-total resections. Tumor resectability, delineation, enhancement pattern, eloquent location, and US image resolution significantly influenced the GTR rate, though only resectability and eloquent location were significant on multivariate analysis.CONCLUSIONSNUS is a useful intraoperative adjunct for resection control in gliomas, detecting unanticipated tumor residues and positively influencing the course of the resection, eventually leading to higher resection rates. Nevertheless, resection is determined by the innate resectability of the tumor and its relationship to eloquent location, reinforcing the need to combine iUS with functional mapping techniques to optimize resections.

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