Indocyanine green fluorescence endoscopy for visual differentiation of pituitary tumor from surrounding structures

Clinical article

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Object

As demonstrated by histological and neuroimaging studies, pituitary adenomas have a capillary vascular density that differs significantly from that of surrounding structures. The authors hypothesized that intraoperative indocyanine green (ICG) fluorescence endoscopy could be used to visually differentiate tumor from surrounding tissues, including normal pituitary gland and dura.

Methods

After institutional review board approval, 16 patients undergoing endoscopic transsphenoidal surgery for benign pituitary lesions were prospectively enrolled in the study. A standard endoscopic endonasal approach to the sella was completed. Each patient then underwent endoscopic examination of the sellar dura and then the exposed pituitary adenoma after ICG bolus injection (12.5–25 mg). This examination was performed using a custom endoscope with a near-infrared light source and excitation wavelength filter.

Results

The authors successfully recorded ICG fluorescence from sellar dura, pituitary, and surrounding structures in 12 of 16 patients enrolled. There were 3 technical failures of intraoperative ICG endoscopy, and 1 patient was excluded following discovery of a dye cross-allergy. A standard dose of 25 mg of ICG in 10 ml of aqueous solution optimized visualization of sellar region microvasculature within 45 seconds of peripheral bolus injection. Adenoma was less fluorescent than normal pituitary gland. Dural invasion by tumor was identifiable by a marked increase in fluorescence compared with native dura. The ICG endoscopic examination added 15–20 minutes of operative time under general anesthesia. There were no complications that resulted from use of ICG or the fluorescent light source.

Conclusions

Indocyanine green fluorescence endoscopy shows promise as an intraoperative modality to visually distinguish pituitary tumors from normal tissue and to visually identify areas of dural invasion, thereby facilitating complete tumor resection and minimizing injury to surrounding structures. These results support the continued development of fluorescence endoscopic resection techniques.

Abbreviations used in this paper:5-ALA = 5-aminolevulinic acid; ICG = indocyanine green; PDD = photodynamic diagnosis.

Article Information

Address correspondence to: Zachary N. Litvack, M.D., M.C.R., Department of Neurosurgery, George Washington University, 2150 Pennsylvania Ave. NW, Suite 7-420, Washington, DC 20037. email: zlitvack@mfa.gwu.edu

Please include this information when citing this paper: published online February 24, 2012; DOI: 10.3171/2012.1.JNS11601.

© AANS, except where prohibited by US copyright law.

Headings

Figures

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    The photodynamic diagnostic system. Components include xenon light source tuned to produce both white light and near-infrared (690–780 nm) light (a) and a high-gain standard definition camera and surgical telescope (b) with a selectable 790 nm filter (inset).

  • View in gallery

    Example of ICG fluorescence highlighting vascular channels within the sellar dura. The images demonstrate the appearance of sellar dura under white light (a) and the same field of view under near-infrared light after injection of ICG.

  • View in gallery

    Example of ICG fluorescence demonstrating relative differences in microvascular density between normal dura and dura invaded by adenoma. The images demonstrate the appearance of a GH-secreting adenoma that has eroded through the sellar dura under white light (a) and the same field of view under near-infrared light after injection of ICG (b). The bright areas correspond to regions where there is no dura covering the tumor.

  • View in gallery

    Example of ICG fluorescence demonstrating relative differences in microvascular density of normal gland and nonfunctioning adenoma. The images demonstrate the appearance of a nonfunctioning adenoma, with a small rim of normal gland (a) and the same field of view under near-infrared light after injection of ICG (b). Note the relative lack of fluorescence from the adenoma compared with the surrounding crescent, corresponding to relative hypovascularity of the adenoma compared with normal pituitary gland.

  • View in gallery

    Example of ICG fluorescence demonstrating relative differences in microvascular density of normal gland and ischemic/infarcted adenoma. The images demonstrate the appearance of an infarcted/necrotic adenoma within the central wedge (a) and the same field of view under near-infrared light after injection of ICG (b). Note the lack of fluorescence from the infarcted tissue, corresponding to lack of blood flow.

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