Wavelength-specific lighted suction instrument for 5-aminolevulinic acid fluorescence-guided resection of deep-seated malignant glioma: technical note

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Surgery guided by 5-aminolevulinic acid (ALA) fluorescence has become a valuable adjunct in the resection of malignant intracranial gliomas. Furthermore, the fluorescence intensity of biopsied areas of a resection cavity correlates with histological identification of tumor cells. However, in the case of lesions deep within a resection cavity, light penetration may be suboptimal, resulting in less excitation of 5-ALA metabolites, leading to decreased fluorescence emission. To address this obstacle, the authors report on the use of a 400-nm wavelength fiber-optic lighted suction instrument that can be used both during resection of a tumor and to provide direct light to deeper areas of a resection cavity. In the presented case, this wavelength-specific lighted suction instrument improved the fluorescence intensity of patches of malignant tissue within the resection cavity. This technique may further improve the utility of 5-ALA in identifying tumor-infiltrated tissue for deep-seated lesions. Additionally, this tool may have implications for scoring systems that correlate 5-ALA fluorescence intensity with histological identification of malignant cells.

ABBREVIATIONS ALA = aminolevulinic acid.

Article Information

Correspondence Ramin Morshed, Department of Neurological Surgery, University of California, San Francisco, 505 Parnassus Ave., Rm. M-779, San Francisco, CA 94143-0112. email: ramin.morshed@ucsf.edu.

INCLUDE WHEN CITING Published online June 30, 2017; DOI: 10.3171/2017.1.JNS161949.

Disclosures The authors report no conflict of interest concerning the materials or methods used in this study or the findings specified in this paper.

© AANS, except where prohibited by US copyright law.

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Figures

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    Components and setup of lighted suction instrument. A Spetzler lighted suction tube (A) was connected to a Luxtec model LX-300 fiber-optic illuminator modified with a 400-nm filter (B). The blue light is directed through the acrylic diffuser (clear portion) both around and in the direction of the suction tip (C and D).

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    Spectrograms of the light source output (A) and light source used against a Zeiss Blue 400 test target demonstrating a wavelength emission peak (asterisk) at 625 nm (B).

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    Intraoperative images of the technique. Two example areas are shown in which low-intensity 5-ALA fluorescence is observed (A and C) but after use of the lighted suction instrument, fluorescence is observed deeper within the resection cavity (B and D). Intraoperative Brainlab navigational guidance confirmed tissue location deep within the prior resection cavity (E and F). Colored outlines represent white matter fiber tracts of different types.

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    The lighted suction instrument did not cause fluorescence when dye-positive tumor tissue was absent.

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    Preoperative and postoperative axial and coronal T1-weighted post-Gd MR images. Preoperative images demonstrated an enhancing focus neighboring the previous resection site (A). After use of the lighted suction instrument to enhance fluorescence-guided tumor removal, postoperative images demonstrate complete resection of the enhancing focus without evidence of excessive tissue damage, other than expected postoperative changes (B).

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