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

Clinical article

View More View Less
  • 1 Department of Neurosurgery, George Washington University, Washington DC;
  • 2 Department of Neurosurgery, Keck School of Medicine, University of Southern California, Los Angeles, California; and
  • 3 Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
Restricted access

Purchase Now

USD  $45.00

JNS + Pediatrics - 1 year subscription bundle (Individuals Only)

USD  $505.00

JNS + Pediatrics + Spine - 1 year subscription bundle (Individuals Only)

USD  $600.00
Print or Print + Online

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.

JNS + Pediatrics - 1 year subscription bundle (Individuals Only)

USD  $505.00

JNS + Pediatrics + Spine - 1 year subscription bundle (Individuals Only)

USD  $600.00

Contributor Notes

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.

  • 1

    Benya R, , Quintana J, & Brundage B: Adverse reactions to indocyanine green: a case report and a review of the literature. Cathet Cardiovasc Diagn 17:231233, 1989

    • Search Google Scholar
    • Export Citation
  • 2

    Bonneville JF, , Bonneville F, & Cattin F: Magnetic resonance imaging of pituitary adenomas. Eur Radiol 15:543548, 2005

  • 3

    Borch JE, , Andersen KE, & Bindslev-Jensen C: The prevalence of suspected and challenge-verified penicillin allergy in a university hospital population. Basic Clin Pharmacol Toxicol 98:357362, 2006

    • Search Google Scholar
    • Export Citation
  • 4

    Desmettre T, , Devoisselle JM, & Mordon S: Fluorescence properties and metabolic features of indocyanine green (ICG) as related to angiography. Surv Ophthalmol 45:1527, 2000

    • Search Google Scholar
    • Export Citation
  • 5

    Eljamel MS, , Leese G, & Moseley H: Intraoperative optical identification of pituitary adenomas. J Neurooncol 92:417421, 2009

  • 6

    Engh JA: Improving intraoperative visualization of anaplastic foci within gliomas. Neurosurgery 67:N21N22, 2010

  • 7

    FDA: Summary of Safety and Effectiveness: Karl Storz D-Light C Photodynamic Diagnosis System Silver Spring, MD, FDA, 2010. (http://www.fda.gov/MedicalDevices/ProductsandMedicalProcedures/DeviceApprovalsandClearances/Recently-ApprovedDevices/ucm215427.htm) [Accessed January 26, 2012]

    • Search Google Scholar
    • Export Citation
  • 8

    Ferroli P, , Acerbi F, , Albanese E, , Tringali G, , Broggi M, & Franzini A, : Application of intraoperative indocyanine green angiography for CNS tumors: results on the first 100 cases. Acta Neurochir Suppl 109:251257, 2011

    • Search Google Scholar
    • Export Citation
  • 9

    Floeth FW, , Sabel M, , Ewelt C, , Stummer W, , Felsberg J, & Reifenberger G, : Comparison of (18)F-FET PET and 5-ALA fluorescence in cerebral gliomas. Eur J Nucl Med Mol Imaging 38:731741, 2011

    • Search Google Scholar
    • Export Citation
  • 10

    He YL, , Tanigami H, , Ueyama H, , Mashimo T, & Yoshiya I: Measurement of blood volume using indocyanine green measured with pulse-spectrophotometry: its reproducibility and reliability. Crit Care Med 26:14461451, 1998

    • Search Google Scholar
    • Export Citation
  • 11

    Jho HD, & Alfieri A: Endoscopic transsphenoidal pituitary surgery: various surgical techniques and recommended steps for procedural transition. Br J Neurosurg 14:432440, 2000

    • Search Google Scholar
    • Export Citation
  • 12

    Jugenburg M, , Kovacs K, , Stefaneanu L, & Scheithauer BW: Vasculature in nontumorous hypophyses, pituitary adenomas, and carcinomas: a quantitative morphologic study. Endocr Pathol 6:115124, 1995

    • Search Google Scholar
    • Export Citation
  • 13

    Kaptain GJ, , Vincent DA, & Laws ER Jr: Cranial base reconstruction after transsphenoidal surgery with bioabsorbable implants. Neurosurgery 48:232234, 2001

    • Search Google Scholar
    • Export Citation
  • 14

    Kepshire DS, , Gibbs-Strauss SL, , O'Hara JA, , Hutchins M, , Mincu N, & Leblond F, : Imaging of glioma tumor with endogenous fluorescence tomography. J Biomed Opt 14:030501-1030501-3, 2009. [Erratum in J Biomed Opt 14:039802, 2009]

    • Search Google Scholar
    • Export Citation
  • 15

    Nabavi A, , Thurm H, , Zountsas B, , Pietsch T, , Lanfermann H, & Pichlmeier U, : Five-aminolevulinic acid for fluorescence-guided resection of recurrent malignant gliomas: a phase ii study. Neurosurgery 65:10701077, 2009

    • Search Google Scholar
    • Export Citation
  • 16

    Potapov AA, , Usachev DJ, , Loshakov VA, , Cherekaev VA, , Kornienko VN, & Pronin IN, : First experience in 5-ALA fluorescence-guided and endoscopically assisted microsurgery of brain tumors. Med Laser Appl 23:202208, 2008

    • Search Google Scholar
    • Export Citation
  • 17

    Raabe A, , Beck J, , Gerlach R, , Zimmermann M, & Seifert V: Nearinfrared indocyanine green video angiography: a new method for intraoperative assessment of vascular flow. Neurosurgery 52:132139, 2003

    • Search Google Scholar
    • Export Citation
  • 18

    Raabe A, , Beck J, & Seifert V: Technique and image quality of intraoperative indocyanine green angiography during aneurysm surgery using surgical microscope integrated near-infrared video technology. Zentralbl Neurochir 66:18, 2005

    • Search Google Scholar
    • Export Citation
  • 19

    Roberts DW, , Valdés PA, , Harris BT, , Fontaine KM, , Hartov A, & Fan 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 114:595603, 2010

    • Search Google Scholar
    • Export Citation
  • 20

    Stenzl A, , Burger M, , Fradet Y, , Mynderse LA, , Soloway MS, & Witjes JA, : Hexaminolevulinate guided fluorescence cystoscopy reduces recurrence in patients with nonmuscle invasive bladder cancer. J Urol 184:19071913, 2010

    • Search Google Scholar
    • Export Citation
  • 21

    Stolik S, , Delgado JA, , Pérez A, & Anasagasti L: Measurement of the penetration depths of red and near infrared light in human “ex vivo” tissues. J Photochem Photobiol B 57:9093, 2000

    • Search Google Scholar
    • Export Citation
  • 22

    Stummer W, , Stocker S, , Wagner S, , Stepp H, , Fritsch C, & Goetz C, : Intraoperative detection of malignant gliomas by 5-aminolevulinic acid-induced porphyrin fluorescence. Neurosurgery 42:518526, 1998

    • Search Google Scholar
    • Export Citation
  • 23

    Tamura Y, , Kuroiwa T, , Kajimoto Y, , Miki Y, , Miyatake S, & Tsuji M: Endoscopic identification and biopsy sampling of an intraventricular malignant glioma using a 5–aminolevulinic acid–induced protoporphyrin IX fluorescence imaging system. Technical note. J Neurosurg 106:507510, 2007

    • Search Google Scholar
    • Export Citation
  • 24

    Tang G, , Cawley CM, , Dion JE, & Barrow DL: Intraoperative angiography during aneurysm surgery: a prospective evaluation of efficacy. J Neurosurg 96:993999, 2002

    • Search Google Scholar
    • Export Citation
  • 25

    Toda M: Intraoperative navigation and fluorescence imagings in malignant glioma surgery. Keio J Med 57:155161, 2008

  • 26

    Wharen RE Jr, , Anderson RE, & Laws ER Jr: Quantitation of hematoporphyrin derivative in human gliomas, experimental central nervous system tumors, and normal tissues. Neurosurgery 12:446450, 1983

    • Search Google Scholar
    • Export Citation
  • 27

    Widhalm G, , Wolfsberger S, , Minchev G, , Woehrer A, , Krssak M, & Czech T, : 5-Aminolevulinic acid is a promising marker for detection of anaplastic foci in diffusely infiltrating gliomas with nonsignificant contrast enhancement. Cancer 116:15451552, 2010

    • Search Google Scholar
    • Export Citation
  • 28

    Witjes JA, , Redorta JP, , Jacqmin D, , Sofras F, , Malmström PU, & Riedl C, : Hexaminolevulinate-guided fluorescence cystoscopy in the diagnosis and follow-up of patients with nonmuscle-invasive bladder cancer: review of the evidence and recommendations. Eur Urol 57:607614, 2010

    • Search Google Scholar
    • Export Citation
  • 29

    Yamada S, & Takada K: Angiogenesis in pituitary adenomas. Microsc Res Tech 60:236243, 2003

Metrics

All Time Past Year Past 30 Days
Abstract Views 692 199 23
Full Text Views 289 24 6
PDF Downloads 187 16 2
EPUB Downloads 0 0 0