Abramov Irakliy, Mathis Andrea M, Xu Yuan, On Thomas J, Belykh Evgenii, Mignucci-Jimenez Giancarlo, Hartke Joelle N, Restelli Francesco, Pollo Bianca, Acerbi Francesco, Schucht Philippe, Porter Randall W, Smith Kris A, Eschbacher Jennifer M, Preul Mark C
1Department of Neurosurgery, The Loyal and Edith Davis Neurosurgical Research Laboratory, St. Joseph's Hospital and Medical Center, Barrow Neurological Institute, Phoenix, Arizona.
2Department of Neurosurgery, Inselspital, Bern University Hospital, University of Bern, Switzerland.
J Neurosurg. 2024 Sep 27;142(2):429-442. doi: 10.3171/2024.5.JNS24140. Print 2025 Feb 1.
Because gliomas have poorly defined tumor margins, the ability to achieve maximal resection is limited. To better discern these margins, fluorescence-guided surgery has been used to aid maximal safe resection. The authors describe their experience with the simultaneous use of intraoperative fluorescein sodium (FNa) confocal laser endomicroscopy (CLE) and operating microscope 5-aminolevulinic acid (5-ALA) fluorescence imaging for glioma resection to improve CLE use for better margin discrimination.
FNa CLE and 5-ALA wide-field imaging were used in 33 patients with gliomas. CLE imaging was enhanced with the use of a telesurgical pathology software platform that enables real-time conversation between the operating neurosurgeons and the pathologists located remotely. CLE was used for imaging tumor regions that were subjectively regarded as tumor margins under normal visualization with the operative microscope. After FNa CLE imaging, 5-ALA wide-field imaging was performed in the same regions. Tissue was biopsied at imaging locations, and interpretations of FNa CLE and 5-ALA wide-field imaging were compared to those of permanent histological sections.
Eighty-eight deep- and superficial-margin regions of interest (ROIs) were imaged with FNa CLE and 5-ALA imaging. Most of the ROIs interpreted by the neuropathologist as infiltrative glioma based on FNa CLE imaging lacked 5-ALA-induced fluorescence. Permanent histological sections from the corresponding regions were concordant with the interpretation of FNa CLE images in 57 of 88 (65%) ROIs and with the interpretation of 5-ALA imaging in 43 of 88 (49%) ROIs. The sensitivity and specificity of FNa CLE for the interpretation of tumor margins were 73% and 41%, respectively, and those of 5-ALA were 38% and 82%, respectively. Positive and negative predictive values for CLE were 79% and 33%, respectively, and those for 5-ALA were 86% and 31%, respectively.
Conventional intraoperative evaluation of tumor margins, based on MRI and wide-field fluorescence imaging, can underestimate the invasiveness of gliomas. FNa CLE showed higher accuracy in detecting regions with infiltrating tumors than intraoperative 5-ALA imaging. Future considerations should include more rigorous comparisons of FNa CLE imaging and 5-ALA-guided resections on a larger cohort of patients.
由于胶质瘤的肿瘤边界不清，实现最大程度切除的能力有限。为了更好地辨别这些边界，荧光引导手术已被用于辅助最大程度的安全切除。作者描述了他们同时使用术中荧光素钠（FNa）共聚焦激光内镜显微镜（CLE）和手术显微镜下5-氨基乙酰丙酸（5-ALA）荧光成像进行胶质瘤切除的经验，以改进CLE的使用，从而更好地辨别边界。
对33例胶质瘤患者使用FNa CLE和5-ALA宽视野成像。通过使用远程手术病理软件平台增强CLE成像，该平台能够使手术神经外科医生与远程病理学家进行实时交流。CLE用于对在手术显微镜正常视野下主观认为是肿瘤边界的肿瘤区域进行成像。在FNa CLE成像后，在相同区域进行5-ALA宽视野成像。在成像部位取组织活检，并将FNa CLE和5-ALA宽视野成像的解读与永久组织学切片的解读进行比较。
用FNa CLE和5-ALA成像对88个深部和浅表边界感兴趣区域（ROI）进行了成像。神经病理学家根据FNa CLE成像解读为浸润性胶质瘤的大多数ROI缺乏5-ALA诱导的荧光。来自相应区域的永久组织学切片在88个ROI中的57个（65%）与FNa CLE图像的解读一致，在88个ROI中的43个（49%）与5-ALA成像的解读一致。FNa CLE对肿瘤边界解读的敏感性和特异性分别为73%和41%，5-ALA的敏感性和特异性分别为38%和82%。CLE的阳性和阴性预测值分别为79%和33%，5-ALA的阳性和阴性预测值分别为86%和31%。
基于MRI和宽视野荧光成像的传统术中肿瘤边界评估可能会低估胶质瘤的侵袭性。FNa CLE在检测浸润性肿瘤区域方面比术中5-ALA成像具有更高的准确性。未来的考虑应包括在更大的患者队列中对FNa CLE成像和5-ALA引导切除进行更严格的比较。
