Navarro-Bonnet Jorge, Suarez-Meade Paola, Brown Desmond A, Chaichana Kaisorn L, Quinones-Hinojosa Alfredo
Department of Neurosurgery, Medica Sur Clinical Foundation, Mexico City, Mexico -
Faculty of Health Sciences, Anahuac University, Mexico City, Mexico -
J Neurosurg Sci. 2019 Dec;63(6):633-647. doi: 10.23736/S0390-5616.19.04745-3.
Gliomas are molecularly complex neoplasms and require a multidisciplinary approach to treatment. Maximal safe resection is often the initial goal of treatment and extent of resection (EOR) is an important prognostic factor correlating with both progression-free-survival (PFS) and overall survival (OS). Postoperative patient outcome is also a critical and independent prognosticator and high EOR must not be achieved at the expense of good functional outcome. Several intraoperative adjuvant techniques have been developed to help the surgeon push the boundaries of EOR while maintaining safety. Fluorescence-guided surgery for brain tumors is a contemporary adjuvant technique that allows for intraoperative delineation of diseased and normal brain thus improving maximal safe resection. The most extensively used fluorophores are 5-aminolevulinic acid (5-ALA) and sodium fluorescein (SFL). These fluorophores have different spectrophotometric properties, mechanisms of action and considerations for use. Both have demonstrated utility in neurosurgical oncology. They are safe and both are FDA approved for use as surgical adjuncts during resection of primary CNS neoplasms although they have been used with varying success for other tumor types. When combined with other surgical adjuvant strategies such as neuronavigation, intraoperative ultrasound, intraoperative MRI, awake resection and/or electrophysiological mapping/monitoring, fluorescence-guided resection appears to further improve resection quality in regard to EOR and safety. In this article, we review the current knowledge related to both fluorophores for brain tumor resection, their benefits, and pitfalls, as well as the major advantages associated with their use. We also briefly review additional fluorophores in early clinical development. Fluorescence-guided surgery is a novel surgical adjuvant which allows for real-time delineation of neoplastic tissues. The most widely used fluorophores are 5-ALA and SFL. They are safe compounds and there is a large body of evidence suggesting improvement in EOR when these are employed. There are nuances to the use of each; the fluorescence intensity is dose-dependent in either case and the sensitivity and specificity for various tumors vary widely. Additional prospective studies will be necessary to parse the impact of this technique and these fluorophores on survival metrics.
胶质瘤是分子结构复杂的肿瘤，需要多学科方法进行治疗。最大限度的安全切除通常是治疗的初始目标，切除范围（EOR）是与无进展生存期（PFS）和总生存期（OS）相关的重要预后因素。术后患者的预后也是一个关键且独立的预后指标，不能以牺牲良好的功能预后为代价来实现高EOR。已经开发了几种术中辅助技术，以帮助外科医生在保持安全的同时扩大EOR的边界。脑肿瘤的荧光引导手术是一种现代辅助技术，可在术中勾勒出病变脑区和正常脑区，从而提高最大限度的安全切除率。使用最广泛的荧光团是5-氨基乙酰丙酸（5-ALA）和荧光素钠（SFL）。这些荧光团具有不同的分光光度特性、作用机制和使用注意事项。两者在神经外科肿瘤学中均已证明有用。它们是安全的，并且均已获得美国食品药品监督管理局（FDA）批准，可在原发性中枢神经系统肿瘤切除术中用作手术辅助剂，尽管它们在其他肿瘤类型中的使用效果各不相同。当与其他手术辅助策略（如神经导航、术中超声、术中磁共振成像、清醒开颅切除和/或电生理图谱/监测）联合使用时，荧光引导切除似乎在EOR和安全性方面进一步提高了切除质量。在本文中，我们回顾了与用于脑肿瘤切除的两种荧光团相关的现有知识、它们的益处和缺陷，以及使用它们的主要优势。我们还简要回顾了处于早期临床开发阶段的其他荧光团。荧光引导手术是一种新型手术辅助技术，可实时勾勒肿瘤组织。使用最广泛的荧光团是5-ALA和SFL。它们是安全的化合物，大量证据表明使用这些荧光团时EOR有所改善。每种荧光团的使用都有细微差别；在任何一种情况下，荧光强度均与剂量相关，并且对各种肿瘤的敏感性和特异性差异很大。需要更多的前瞻性研究来分析该技术和这些荧光团对生存指标的影响。
