Intraoperative confocal microscopy in the visualization of 5-aminolevulinic acid fluorescence in low-grade gliomas

Clinical article

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Object

Greater extent of resection (EOR) for patients with low-grade glioma (LGG) corresponds with improved clinical outcome, yet remains a central challenge to the neurosurgical oncologist. Although 5-aminolevulinic acid (5-ALA)–induced tumor fluorescence is a strategy that can improve EOR in gliomas, only glioblastomas routinely fluoresce following 5-ALA administration. Intraoperative confocal microscopy adapts conventional confocal technology to a handheld probe that provides real-time fluorescent imaging at up to 1000× magnification. The authors report a combined approach in which intraoperative confocal microscopy is used to visualize 5-ALA tumor fluorescence in LGGs during the course of microsurgical resection.

Methods

Following 5-ALA administration, patients with newly diagnosed LGG underwent microsurgical resection. Intraoperative confocal microscopy was conducted at the following points: 1) initial encounter with the tumor; 2) the midpoint of tumor resection; and 3) the presumed brain-tumor interface. Histopathological analysis of these sites correlated tumor infiltration with intraoperative cellular tumor fluorescence.

Results

Ten consecutive patients with WHO Grades I and II gliomas underwent microsurgical resection with 5-ALA and intraoperative confocal microscopy. Macroscopic tumor fluorescence was not evident in any patient. However, in each case, intraoperative confocal microscopy identified tumor fluorescence at a cellular level, a finding that corresponded to tumor infiltration on matched histological analyses.

Conclusions

Intraoperative confocal microscopy can visualize cellular 5-ALA–induced tumor fluorescence within LGGs and at the brain-tumor interface. To assess the clinical value of 5-ALA for high-grade gliomas in conjunction with neuronavigation, and for LGGs in combination with intraoperative confocal microscopy and neuronavigation, a Phase IIIa randomized placebo-controlled trial (BALANCE) is underway at the authors' institution.

Abbreviations used in this paper: 5-ALA = 5-aminolevulinic acid; BALANCE = Barrow ALA Intraoperative Confocal Evaluation; BNI = Barrow Neurological Institute; EOR = extent of resection; GTR = gross-total resection; HGG = high-grade glioma; LGG = low-grade glioma; NIHSS = National Institutes of Health Stroke Scale; ROI = region of interest.

Article Information

Address correspondence to: Nader Sanai, M.D., Division of Neurosurgical Oncology, Barrow Brain Tumor Research Center, Barrow Neurological Institute, 2910 North Third Avenue, Phoenix, Arizona 85013. email: nader.sanai@bnaneuro.net.

Please include this information when citing this paper: published online July 15, 2011; DOI: 10.3171/2011.6.JNS11252.

© AANS, except where prohibited by US copyright law.

Headings

Figures

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    Microscopic 5-ALA tumor fluorescence detected in a WHO Grade II glioma by using intraoperative confocal microscopy. A: Axial MR image obtained in a 21-year-old man in whom a right frontal LGG was detected incidentally following a motor vehicle accident. B: Intraoperative view; the handheld confocal microscope was used in the absence of macroscopic 5-ALA tumor fluorescence. C: Intraoperative neuronavigation studies confirming localization of the confocal imaging within the tumor mass. D: Multiple fluorescent cells were observed within this region, corresponding to 5-ALA metabolism. E: Postoperative axial FLAIR MR imaging study confirming a 98% volumetric EOR.

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    Identification of LGG tumor margins by using confocal microscopy and 5-ALA tumor fluorescence. A: Axial MR image obtained in a 39-year-old woman with a right parietal WHO Grade II glioma who underwent routine microsurgical resection. B: Intraoperative neuronavigation studies identifying a resection cavity margin as radiographically free of tumor. C: Results of intraoperative confocal microscopy at this site were negative, suggesting an absence of infiltrating LGG. D: Histological analysis of this same region, with an H & E–stained section confirming the absence of tumor. Original magnification × 40. E: Intraoperative neuronavigation studies identifying the presumed margin of the brain-tumor interface. F: Macroscopic 5-ALA tumor fluorescence was not evident, and a region of the cavity wall (box) was analyzed using intraoperative confocal microscopy. G: Image of the same region revealing evidence of persistent fluorescent tumor infiltration. H: Corresponding histopathological analysis of this ROI, with an H & E–stained section confirming the presence of infiltrating tumor, including cells with nuclear atypia (arrows). Original magnification × 40. I: Postoperative axial FLAIR MR imaging study confirming a 99% volumetric EOR.

  • View in gallery

    Intraoperative confocal microscopy visualization of 5-ALA cellular fluorescence in a transforming WHO Grade II/III oligodendroglioma. A: Axial MR image obtained in a 37-year-old woman who presented with new-onset seizures and a nonenhancing right supplementary motor area mass. B: During microsurgical resection, intraoperative neuronavigation confirmed localization of the confocal imaging within the tumor mass. C: Macroscopic 5-ALA tumor fluorescence was not evident, and a region of the tumor (box) was analyzed using intraoperative confocal microscopy. D: Image of the same region revealing 5-ALA–induced tumor fluorescence. E: Correlative analysis of this site with an H & E–stained section identifying it as a focal region of WHO Grade III histological characteristics, as evidenced by the presence of microvascular proliferation (arrows). Original magnification × 40. F: Within this same region, atypical mitotic figures (arrow) were also encountered on an H & E–stained section. Original magnification × 80. G: Postoperative axial FLAIR MR imaging study confirming a 100% volumetric EOR.

References

1

Ahmadi RDictus CHartmann CZürn OEdler LHartmann M: Long-term outcome and survival of surgically treated supratentorial low-grade glioma in adult patients. Acta Neurochir (Wien) 151:135913652009. (Erratum in Acta Neurochir (Wien) 161:1367 2009)

2

Black PMAlexander E IIIMartin CMoriarty TNabavi AWong TZ: Craniotomy for tumor treatment in an intraoperative magnetic resonance imaging unit. Neurosurgery 45:4234331999

3

Brown PDMaurer MJRummans TAPollock BEBallman KVSloan JA: A prospective study of quality of life in adults with newly diagnosed high-grade gliomas: the impact of the extent of resection on quality of life and survival. Neurosurgery 57:4955042005

4

Cavaliere RLopes MBSchiff D: Low-grade gliomas: an update on pathology and therapy. Lancet Neurol 4:7607702005

5

Chaichana KLHalthore ANParker SLOlivi AWeingart JDBrem H: Factors involved in maintaining prolonged functional independence following supratentorial glioblastoma resection. Clinical article. J Neurosurg 114:6046122011

6

Chaichana KLKosztowski TNiranjan AOlivi AWeingart JDLaterra J: Prognostic significance of contrastenhancing anaplastic astrocytomas in adults. Clinical article. J Neurosurg 113:2862922010

7

Chang EFSmith JSChang SMLamborn KRPrados MDButowski N: Preoperative prognostic classification system for hemispheric low-grade gliomas in adults. Clinical article. J Neurosurg 109:8178242008

8

Claus EBHorlacher AHsu LSchwartz RBDello-Iacono DTalos F: Survival rates in patients with low-grade glioma after intraoperative magnetic resonance image guidance. Cancer 103:122712332005

9

Coenen VAKrings TWeidemann JHans FJReinacher PGilsbach JM: Sequential visualization of brain and fiber tract deformation during intracranial surgery with threedimensional ultrasound: an approach to evaluate the effect of brain shift. Neurosurgery 56:1 Suppl1331412005

10

Duffner FRitz RFreudenstein DWeller MDietz KWessels J: Specific intensity imaging for glioblastoma and neural cell cultures with 5-aminolevulinic acid-derived protoporphyrin IX. J Neurooncol 71:1071112005

11

El-Hateer HSouhami LRoberge DMaestro RDLeblanc REldebawy E: Low-grade oligodendroglioma: an indolent but incurable disease? Clinical article. J Neurosurg 111:2652712009

12

Floeth FWSabel MEwelt CStummer WFelsberg JReifenberger G: Comparison of (18)F-FET PET and 5-ALA fluorescence in cerebral gliomas. Eur J Nucl Med Mol Imaging 38:7317412011

13

Hall WALiu HMaxwell RETruwit CL: Influence of 1.5-Tesla intraoperative MR imaging on surgical decision making. Acta Neurochir Suppl 85:29372003

14

Hatiboglu MAWeinberg JSSuki DRao GPrabhu SSShah K: Impact of intraoperative high-field magnetic resonance imaging guidance on glioma surgery: a prospective volumetric analysis. Neurosurgery 64:107310812009

15

Hirschberg HSamset EHol PKTillung TLote K: Impact of intraoperative MRI on the surgical results for high-grade gliomas. Minim Invasive Neurosurg 48:77842005

16

Ishihara RKatayama YWatanabe TYoshino AFukushima TSakatani K: Quantitative spectroscopic analysis of 5-aminolevulinic acid-induced protoporphyrin IX fluorescence intensity in diffusely infiltrating astrocytomas. Neurol Med Chir (Tokyo) 47:53572007

17

Johannesen TBLangmark FLote K: Progress in long-term survival in adult patients with supratentorial low-grade gliomas: a population-based study of 993 patients in whom tumors were diagnosed between 1970 and 1993. J Neurosurg 99:8548622003

18

Keles GELamborn KRBerger MS: Low-grade hemispheric gliomas in adults: a critical review of extent of resection as a factor influencing outcome. J Neurosurg 95:7357452001

19

Krishnan RRaabe AHattingen ESzelenyi AYahya HHermann E: Functional magnetic resonance imaging-integrated neuronavigation: correlation between lesion-to-motor cortex distance and outcome. Neurosurgery 55:9049052004

20

Kurimoto MHayashi NKamiyama HNagai SShibata TAsahi T: Impact of neuronavigation and image-guided extensive resection for adult patients with supratentorial malignant astrocytomas: a single-institution retrospective study. Minim Invasive Neurosurg 47:2782832004

21

Liao HNoguchi MMaruyama TMuragaki YKobayashi EIseki H: An integrated diagnosis and therapeutic system using intra-operative 5-aminolevulinic-acid-induced fluorescence guided robotic laser ablation for precision neurosurgery. Med Image Anal [epub ahead of print]2010

22

Mansur DBHekmatpanah JWollman RMacdonald LNicholas KBeckmann E: Low grade gliomas treated with adjuvant radiation therapy in the modern imaging era. Am J Clin Oncol 23:2222262000

23

McGirt MJChaichana KLAttenello FJWeingart JDThan KBurger PC: Extent of surgical resection is independently associated with survival in patients with hemispheric infiltrating low-grade gliomas. Neurosurgery 63:7007082008

24

Nabavi AThurm HZountsas BPietsch TLanfermann HPichlmeier U: Five-aminolevulinic acid for fluorescenceguided resection of recurrent malignant gliomas: a phase II study. Neurosurgery 65:107010772009

25

Nakamura MKonishi NTsunoda SNakase HTsuzuki TAoki H: Analysis of prognostic and survival factors related to treatment of low-grade astrocytomas in adults. Oncology 58:1081162000

26

Nikas DCHartov ALunn KRick KPaulsen KRoberts DW: Coregistered intraoperative ultrasonography in resection of malignant glioma. Neurosurg Focus 14:2e62003

27

Nimsky CFujita AGanslandt OVon Keller BFahlbusch R: Volumetric assessment of glioma removal by intraoperative high-field magnetic resonance imaging. Neurosurgery 55:3583712004

28

Pamir MNOzduman KDinçer AYildiz EPeker SOzek MM: First intraoperative, shared-resource, ultrahigh-field 3-Tesla magnetic resonance imaging system and its application in low-grade glioma resection. Clinical article. J Neurosurg 112:57692010

29

Piepmeier JM: Current concepts in the evaluation and management of WHO grade II gliomas. J Neurooncol 92:2532592009

30

Pouratian NAsthagiri AJagannathan JShaffrey MESchiff D: Surgery insight: the role of surgery in the management of low-grade gliomas. Nat Clin Pract Neurol 3:6286392007

31

Reinacher PCvan Velthoven V: Intraoperative ultrasound imaging: practical applicability as a real-time navigation system. Acta Neurochir Suppl 85:89932003

32

Reithmeier TKrammer MGumprecht HGerstner WLumenta CB: Neuronavigation combined with electrophysiological monitoring for surgery of lesions in eloquent brain areas in 42 cases: a retrospective comparison of the neurological outcome and the quality of resection with a control group with similar lesions. Minim Invasive Neurosurg 46:65712003

33

Roberts DWValdés PAHarris BTFontaine KMHartov AFan X: Coregistered fluorescence-enhanced tumor resection of malignant glioma: relationships between δ-aminolevulinic acid-induced protoporphyrin IX fluorescence, magnetic resonance imaging enhancement, and neuropathological parameters. Clinical article. J Neurosurg 114:5956032011

34

Sanai NBerger MS: Glioma extent of resection and its impact on patient outcome. Neurosurgery 62:7532662008

35

Sanai NEschbacher JHattendorf GCoons SWPreul MCSmith KA: Intraoperative confocal microscopy for brain tumors: a feasibility analysis in humans. Neurosurgery [epub ahead of print]2011

36

Sanai NPolley MYBerger MS: Insular glioma resection: assessment of patient morbidity, survival, and tumor progression. Clinical article. J Neurosurg 112:192010

37

Sankar TDelaney PMRyan RWEschbacher JAbdelwahab MNakaji P: Miniaturized handheld confocal microscopy for neurosurgery: results in an experimental glioblastoma model. Neurosurgery 66:4104182010

38

Schneider JPSchulz TSchmidt FDietrich JLieberenz STrantakis C: Gross-total surgery of supratentorial low-grade gliomas under intraoperative MR guidance. AJNR Am J Neuroradiol 22:89982001

39

Senft CBink AHeckelmann MGasser TSeifert V: Glioma extent of resection and ultra-low-field iMRI: interim analysis of a prospective randomized trial. Acta Neurochir Suppl 109:49532011

40

Senft CSeifert VHermann EFranz KGasser T: Usefulness of intraoperative ultra low-field magnetic resonance imaging in glioma surgery. Neurosurgery 63:4 Suppl 22572672008

41

Shaw EArusell RScheithauer BO'Fallon JO'Neill BDinapoli R: Prospective randomized trial of low-versus high-dose radiation therapy in adults with supratentorial lowgrade glioma: initial report of a North Central Cancer Treatment Group/Radiation Therapy Oncology Group/Eastern Cooperative Oncology Group study. J Clin Oncol 20:226722762002

42

Smith JSChang EFLamborn KRChang SMPrados MDCha S: Role of extent of resection in the long-term outcome of low-grade hemispheric gliomas. J Clin Oncol 26:133813452008

43

Stark AMNabavi AMehdorn HMBlömer U: Glioblastoma multiforme—report of 267 cases treated at a single institution. Surg Neurol 63:1621692005

44

Stockhammer FMisch MHorn PKoch AFonyuy NPlotkin M: Association of F18-fluoro-ethyl-tyrosin uptake and 5-aminolevulinic acid-induced fluorescence in gliomas. Acta Neurochir (Wien) 151:137713832009

45

Stummer WPichlmeier UMeinel TWiestler ODZanella FReulen HJ: Fluorescence-guided surgery with 5-aminolevulinic acid for resection of malignant glioma: a randomised controlled multicentre phase III trial. Lancet Oncol 7:3924012006

46

Stummer WReulen HJNovotny AStepp HTonn JC: Fluorescence-guided resections of malignant gliomas–an overview. Acta Neurochir Suppl 88:9122003

47

Stummer WStepp HMöller GEhrhardt ALeonhard MReulen HJ: Technical principles for protoporphyrin-IX-fluorescence guided microsurgical resection of malignant glioma tissue. Acta Neurochir (Wien) 140:99510001998

48

Tonn JCStummer W: Fluorescence-guided resection of malignant gliomas using 5-aminolevulinic acid: practical use, risks, and pitfalls. Clin Neurosurg 55:20262008

49

Unsgaard GSelbekk TBrostrup Müller TOmmedal STorp SHMyhr G: Ability of navigated 3D ultrasound to delineate gliomas and metastases—comparison of image interpretations with histopathology. Acta Neurochir (Wien) 147:125912692005

50

Ushio YKochi MHamada JKai YNakamura H: Effect of surgical removal on survival and quality of life in patients with supratentorial glioblastoma. Neurol Med Chir (Tokyo) 45:4544612005

51

Van Meir EGHadjipanayis CGNorden ADShu HKWen PYOlson JJ: Exciting new advances in neuro-oncology: the avenue to a cure for malignant glioma. CA Cancer J Clin 60:1661932010

52

Warnke PC: Stereotactic volumetric resection of gliomas. Acta Neurochir Suppl 88:582003

53

Widhalm GWolfsberger SMinchev GWoehrer AKrssak MCzech T: 5-Aminolevulinic acid is a promising marker for detection of anaplastic foci in diffusely infiltrating gliomas with nonsignificant contrast enhancement. Cancer 116:154515522010

54

Willems PWTaphoorn MJBurger HBerkelbach van der Sprenkel JWTulleken CA: Effectiveness of neuronavigation in resecting solitary intracerebral contrast-enhancing tumors: a randomized controlled trial. J Neurosurg 104:3603682006

55

Wu JSZhou LFTang WJMao YHu JSong YY: Clinical evaluation and follow-up outcome of diffusion tensor imaging-based functional neuronavigation: a prospective, controlled study in patients with gliomas involving pyramidal tracts. Neurosurgery 61:9359492007

56

Yeh SAHo JTLui CCHuang YJHsiung CYHuang EY: Treatment outcomes and prognostic factors in patients with supratentorial low-grade gliomas. Br J Radiol 78:2302352005

57

Yeh SALee TCChen HJLui CCSun LMWang CJ: Treatment outcomes and prognostic factors of patients with supratentorial low-grade oligodendroglioma. Int J Radiat Oncol Biol Phys 54:140514092002

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