Fluorescence-Based Measurement of Real-Time Kinetics of Protoporphyrin IX After 5-Aminolevulinic Acid Administration in Human In Situ Malignant Gliomas

Abstract BACKGROUND Five-aminolevulinic acid (5-ALA) is well established for fluorescence-guided resections of malignant gliomas by eliciting the accumulation of fluorescent protoporphyrin IX (PpIX) in tumors. Because of the assumed time point of peak fluorescence, 5-ALA is recommended to be administered 3 h before surgery. However, the actual time dependency of tumor fluorescence has not yet been evaluated in humans and may have important implications. OBJECTIVE To investigate the time dependency of PpIX by measuring fluorescence intensities in tumors at various time points during surgery. METHODS Patients received 5-ALA (20 mg/kg b.w.) 3 to 4 h before surgery. Fluorescence intensities (FI) and estimated tumor PpIX concentrations (CPPIX) were measured in the tumors over time with a hyperspectral camera. CPPIX was assessed using hyperspectral imaging and by evaluating fluorescence phantoms with known CPPIX. RESULTS A total of 201 samples from 68 patients were included in this study. On average, maximum values of calculated FI and CPPIX were observed between 7 and 8 h after 5-ALA administration. FI and CPPIX both reliably distinguished central strong and marginal weak fluorescence, and grade III compared to grade IV gliomas. Interestingly, marginal (weak) fluorescence was observed to peak later than strong fluorescence (8-9 vs 7-8 h). CONCLUSION In human in Situ brain tumor tissue, we determined fluorescence after 5-ALA administration to be maximal later than previously thought. In consequence, 5-ALA should be administered 4 to 5 h before surgery, with timing adjusted to internal logistical circumstances and factors related to approaching the tumor.

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Kinetics of protoporphyrin IX formation in rat oral mucosa and skin after application of 5-aminolevulinic acid and its methylester

Photochemistry and Photobiology ◽

10.1562/2004-04-02-ra-132 ◽

2004 ◽

Author(s):

Stefan Kristiansson ◽

Asta Juzeniene ◽

Petras Juzenas ◽

Vladimir Iani ◽

Lennart Löfgren ◽

...

Keyword(s):

Oral Mucosa ◽

Aminolevulinic Acid ◽

Protoporphyrin Ix ◽

Kinetics Of

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Macroscopic fluorescence-lifetime imaging of NADH and protoporphyrin IX improves the detection and grading of 5-aminolevulinic acid-stained brain tumors

Scientific Reports ◽

10.1038/s41598-020-77268-8 ◽

2020 ◽

Vol 10 (1) ◽

Author(s):

Mikael T. Erkkilä ◽

David Reichert ◽

Johanna Gesperger ◽

Barbara Kiesel ◽

Thomas Roetzer ◽

...

Keyword(s):

Brain Tumor ◽

Brain Tumors ◽

Fluorescence Lifetime ◽

Tumor Tissue ◽

Aminolevulinic Acid ◽

Protoporphyrin Ix ◽

Low Grade ◽

Wide Field ◽

Fluorescence Lifetime Imaging ◽

Lifetime Imaging

AbstractMaximal safe tumor resection remains the key prognostic factor for improved prognosis in brain tumor patients. Despite 5-aminolevulinic acid-based fluorescence guidance the neurosurgeon is, however, not able to visualize most low-grade gliomas (LGG) and infiltration zone of high-grade gliomas (HGG). To overcome the need for a more sensitive visualization, we investigated the potential of macroscopic, wide-field fluorescence lifetime imaging of nicotinamide adenine dinucleotide (NADH) and protoporphyrin IX (PPIX) in selected human brain tumors. For future intraoperative use, the imaging system offered a square field of view of 11 mm at 250 mm free working distance. We performed imaging of tumor tissue ex vivo, including LGG and HGG as well as brain metastases obtained from 21 patients undergoing fluorescence-guided surgery. Half of all samples showed visible fluorescence during surgery, which was associated with significant increase in PPIX fluorescence lifetime. While the PPIX lifetime was significantly different between specific tumor tissue types, the NADH lifetimes did not differ significantly among them. However, mainly necrotic areas exhibited significantly lower NADH lifetimes compared to compact tumor in HGG. Our pilot study indicates that combined fluorescence lifetime imaging of NADH/PPIX represents a sensitive tool to visualize brain tumor tissue not detectable with conventional 5-ALA fluorescence.

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Influence of Light Exposure on the Kinetics of Protoporphyrin IX Formation in Normal Skin of Hairless Mice After Application of 5-Aminolevulinic Acid Methyl Ester

Journal of Investigative Dermatology ◽

10.1111/j.0022-202x.2005.23863.x ◽

2005 ◽

Vol 125 (5) ◽

pp. 1039-1044 ◽

Cited By ~ 10

Author(s):

Johan Moan ◽

LiWei Ma ◽

Vladimir Iani ◽

Asta Juzeniene

Keyword(s):

Methyl Ester ◽

Aminolevulinic Acid ◽

Light Exposure ◽

Normal Skin ◽

Protoporphyrin Ix ◽

Acid Methyl Ester ◽

Hairless Mice ◽

Acid Methyl ◽

Kinetics Of

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Characterizing the heterogeneity in 5-aminolevulinic acid–induced fluorescence in glioblastoma

Journal of Neurosurgery ◽

10.3171/2019.2.jns183128 ◽

2020 ◽

Vol 132 (6) ◽

pp. 1706-1714 ◽

Cited By ~ 4

Author(s):

Damian A. Almiron Bonnin ◽

Matthew C. Havrda ◽

Myung Chang Lee ◽

Linton Evans ◽

Cong Ran ◽

...

Keyword(s):

Gene Expression ◽

Tumor Tissue ◽

Aminolevulinic Acid ◽

Expression Profiles ◽

Expression Patterns ◽

Protoporphyrin Ix ◽

Progression Free Survival ◽

The Cancer Genome Atlas ◽

Diagnostic Challenge ◽

Biological Basis

OBJECTIVE5-aminolevulinic acid (5-ALA)–induced protoporphyrin IX (PpIX) fluorescence is an effective surgical adjunct for the intraoperative identification of tumor tissue during resection of high-grade gliomas. The use of 5-ALA-induced PpIX fluorescence in glioblastoma (GBM) has been shown to double the extent of gross-total resection and 6-month progression-free survival. The heterogeneity of 5-ALA-induced PpIX fluorescence observed during surgery presents a technical and diagnostic challenge when utilizing this tool intraoperatively. While some regions show bright fluorescence after 5-ALA administration, other regions do not, despite that both regions of the tumor may be histopathologically indistinguishable. The authors examined the biological basis of this heterogeneity using computational methods.METHODSThe authors collected both fluorescent and nonfluorescent GBM specimens from a total of 14 patients undergoing surgery and examined their gene expression profiles.RESULTSIn this study, the authors found that the gene expression patterns characterizing fluorescent and nonfluorescent GBM surgical specimens were profoundly different and were associated with distinct cellular functions and different biological pathways. Nonfluorescent tumor tissue tended to resemble the neural subtype of GBM; meanwhile, fluorescent tumor tissue did not exhibit a prominent pattern corresponding to known subtypes of GBM. Consistent with this observation, neural GBM samples from The Cancer Genome Atlas database exhibited a significantly lower fluorescence score than nonneural GBM samples as determined by a fluorescence gene signature developed by the authors.CONCLUSIONSThese results provide a greater understanding regarding the biological basis of differential fluorescence observed intraoperatively and can provide a basis to identify novel strategies to maximize the effectiveness of fluorescence agents.

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Fluorescence-Guided Resection of Malignant Glioma with 5-ALA

International Journal of Biomedical Imaging ◽

10.1155/2016/6135293 ◽

2016 ◽

Vol 2016 ◽

pp. 1-11 ◽

Cited By ~ 21

Author(s):

Sadahiro Kaneko ◽

Sadao Kaneko

Keyword(s):

Malignant Glioma ◽

Anticancer Agents ◽

Aminolevulinic Acid ◽

Malignant Gliomas ◽

Protoporphyrin Ix ◽

Time Spectrum ◽

Photodynamic Diagnosis ◽

Promising Technique ◽

New Methods ◽

New Treatments

Malignant gliomas are extremely difficult to treat with no specific curative treatment. On the other hand, photodynamic medicine represents a promising technique for neurosurgeons in the treatment of malignant glioma. The resection rate of malignant glioma has increased from 40% to 80% owing to 5-aminolevulinic acid-photodynamic diagnosis (ALA-PDD). Furthermore, ALA is very useful because it has no serious complications. Based on previous research, it is apparent that protoporphyrin IX (PpIX) accumulates abundantly in malignant glioma tissues after ALA administration. Moreover, it is evident that the mechanism underlying PpIX accumulation in malignant glioma tissues involves an abnormality in porphyrin-heme metabolism, specifically decreased ferrochelatase enzyme activity. During resection surgery, the macroscopic fluorescence of PpIX to the naked eye is more sensitive than magnetic resonance imaging, and the alert real time spectrum of PpIX is the most sensitive method. In the future, chemotherapy with new anticancer agents, immunotherapy, and new methods of radiotherapy and gene therapy will be developed; however, ALA will play a key role in malignant glioma treatment before the development of these new treatments. In this paper, we provide an overview and present the results of our clinical research on ALA-PDD.

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The Fluorescence Biodistribution And Kinetics Of Aminolevulinic Acid Induced Protoporphyrin IX In The Bladder Of A Rat Model With Orthotopic Urothelial Carcinoma

The Journal of Urology ◽

10.1016/s0022-5347(05)65247-0 ◽

2002 ◽

Vol 167 (4) ◽

pp. 1848-1853 ◽

Cited By ~ 5

Author(s):

Sari Grönlund-Pakkanen ◽

Jarmo Wahlfors ◽

Kimmo Mäkinen ◽

Timo M. Pakkanen ◽

Martti Talja ◽

...

Keyword(s):

Urothelial Carcinoma ◽

Rat Model ◽

Aminolevulinic Acid ◽

Protoporphyrin Ix ◽

Kinetics Of

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Protoporphyrin-IX Distribution and Photodynamic Effect in Rat Oesophagus after Aminolevulinic Acid Administration

Scandinavian Journal of Gastroenterology ◽

10.3109/00365529708996510 ◽

1997 ◽

Vol 32 (7) ◽

pp. 633-637 ◽

Cited By ~ 8

Author(s):

K. Mäkinen ◽

S. Grönlund-Pakkanen ◽

M. Tiirikainen ◽

P. Nuutinen ◽

A. Kuusisto ◽

...

Keyword(s):

Aminolevulinic Acid ◽

Protoporphyrin Ix ◽

Photodynamic Effect ◽

Acid Administration

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Fluorescence real-time kinetics of protoporphyrin IX after 5-ALA administration in low-grade glioma

Journal of Neurosurgery ◽

10.3171/2020.10.jns202881 ◽

2021 ◽

pp. 1-7

Author(s):

Sadahiro Kaneko ◽

Eric Suero Molina ◽

Peter Sporns ◽

Stephanie Schipmann ◽

David Black ◽

...

Keyword(s):

Real Time ◽

Aminolevulinic Acid ◽

Protoporphyrin Ix ◽

Low Grade Glioma ◽

Low Grade ◽

Gadolinium Contrast ◽

Ki 67 ◽

Fet Pet ◽

Kinetics Of ◽

Mib 1

OBJECTIVE 5-Aminolevulinic acid (5-ALA) induces fluorescence in high-grade glioma (HGG), which is used for resection. However, the value of 5-ALA–induced fluorescence in low-grade glioma (LGG) is unclear. Time dependency and time kinetics have not yet been investigated. The purpose of this study was to investigate real-time kinetics of protoporphyrin IX (PpIX) in LGG based on hyperspectral fluorescence-based measurements and identify factors that predict fluorescence. METHODS Patients with grade II gliomas and imaging from which HGGs could not be completely ruled out received 5-ALA at 20 mg/kg body weight 4 hours prior to surgery. Fluorescence intensity (FI) and PpIX concentration (CPpIX) were measured in tumor tissue utilizing a hyperspectral camera. Apparent diffusion coefficient (ADC)–based tumor cell density, Ki-67/MIB-1 index, chromosomal 1p/19q codeletion, and 18F-fluoroethyl-l-tyrosine (18F-FET) PET values and their role for predicting fluorescence were evaluated. RESULTS Eighty-one biopsies from 25 patients were included. Tissues with fluorescence demonstrated FI and CPpIX maxima between 7 and 8 hours after administration. When visible fluorescence was observed, peaks of FI and CPpIX were observed within this 7- to 8-hour time frame, regardless of any MRI gadolinium contrast enhancement. Gadolinium enhancement (p = 0.008), Ki-67/MIB-1 index (p < 0.001), 18F-FET PET uptake ratio (p = 0.004), and ADC-based tumor cellularity (p = 0.017) significantly differed between fluorescing and nonfluorescing tissue, but not 1p/19q codeletions. Logistic regression demonstrated that 18F-FET PET uptake and Ki-67/MIB-1 index were independently related to fluorescence. CONCLUSIONS This study reports a fluorescence-based assessment of CPpIX in human LGG tissues related to 18F-FET PET uptake and Ki-67/MIB-1. As in HGGs, fluorescence in LGGs peaked between 7 and 8 hours after 5-ALA application, which has consequences for the timing of administration.

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