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Use of Fluorescence to Guide Resection Or Biopsy of Primary Brain Tumors and Brain Metastases

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Use of Fluorescence to Guide Resection Or Biopsy of Primary Brain Tumors and Brain Metastases Neurosurg Focus 36 (2):E10, 2014 ©AANS, 2014 Use of fluorescence to guide resection or biopsy of primary brain tumors and brain metastases *SERGE MARBACHER, M.D., M.SC.,1,5 ELISABETH KLINGER, M.D.,2 LUCIA SCHWYZER, M.D.,1,5 INGEBORG FISCHER, M.D.,3 EDIN NEVZATI, M.D.,1 MICHAEL DIEPERS, M.D.,2,5 ULRICH ROELCKE, M.D.,4,5 ALI-REZA FATHI, M.D.,1,5 DANIEL COLUCCIA, M.D.,1,5 AND JAVIER FANDINO, M.D.1,5 Departments of 1Neurosurgery, 2Neuroradiology, 3Pathology, and 4Neurology, and 5Brain Tumor Center, Kantonsspital Aarau, Aarau, Switzerland Object. The accurate discrimination between tumor and normal tissue is crucial for determining how much to resect and therefore for the clinical outcome of patients with brain tumors. In recent years, guidance with 5-aminolev- ulinic acid (5-ALA)–induced intraoperative fluorescence has proven to be a useful surgical adjunct for gross-total resection of high-grade gliomas. The clinical utility of 5-ALA in resection of brain tumors other than glioblastomas has not yet been established. The authors assessed the frequency of positive 5-ALA fluorescence in a cohort of pa- tients with primary brain tumors and metastases. Methods. The authors conducted a single-center retrospective analysis of 531 patients with intracranial tumors treated by 5-ALA–guided resection or biopsy. They analyzed patient characteristics, preoperative and postoperative liver function test results, intraoperative tumor fluorescence, and histological data. They also screened discharge summaries for clinical adverse effects resulting from the administration of 5-ALA. Intraoperative qualitative 5-ALA fluorescence (none, mild, moderate, and strong) was documented by the surgeon and dichotomized into negative and positive fluorescence. Results. A total of 458 cases qualified for final analysis. The highest percentage of 5-ALA–positive fluorescence in open resection was found in glioblastomas (96%, n = 99/103). Among other tumors, 5-ALA–positive fluorescence was detected in 88% (n = 21/32) of anaplastic gliomas (WHO Grade III), 40% (n = 8/19) of low-grade gliomas (WHO Grade II), no (n = 0/3) WHO Grade I gliomas, and 77% (n = 85/110) of meningiomas. Among metastases, the high- est percentage of 5-ALA–positive fluorescence was detected in adenocarcinomas (48%, n = 13/27). Low rates or absence of positive fluorescence was found among pituitary adenomas (8%, n = 1/12) and schwannomas (0%, n = 0/7). Biopsies of high-grade primary brain tumors showed positive rates of fluorescence similar to those recorded for open resection. No clinical adverse effects associated with use of 5-ALA were observed. Only 1 patient had clinically silent transient elevation of liver enzymes. Conclusions. Study findings suggest that the administration of 5-ALA as a surgical adjunct for resection and biopsy of primary brain tumors and brain metastases is safe. In light of the high rate of positive fluorescence in high- grade gliomas other than glioblastomas, meningiomas, and a variety of metastatic cancers, 5-ALA seems to be a promising tool for enhancing intraoperative identification of neoplastic tissue and optimizing the extent of resection. (http://thejns.org/doi/abs/10.3171/2013.12.FOCUS13464) KEY WORDS • 5-ALA • protoporphyrin IX • Gliolan • fluorescence • brain tumor • metastasis • biopsy XTENT of resection is an important prognostic factor erative oral administration of 5-aminolevulinic acid (5- that affects survival times for most patients with ALA) improves the intraoperative visualization of tumor primary or secondary malignant brain tumors.22,23,34 with a blue-violet light source.30,38–40,45,49 For a series of EHowever, during open tumor resection, it is often difficult patients with glioblastoma who underwent 5-ALA–guid- to distinguish between normal brain and neoplastic tissue ed tumor resection, radiologically confirmed complete and to identify tumor margins,16,24,32 and during stereo- resection rates of up to 83% were recently reported.6 tactic biopsy of brain tumors, the sampling of positive A growing body of evidence indicates that the extent pathological tissue specimens can be challenging.25 For of tumor resection and therefore overall survival times patients with glioblastoma (WHO Grade IV), the preop- for patients with glioblastoma can be positively influ- enced by 5-ALA fluorescence–guided surgery.30,39,45,49 In recent years, interest has increased in the assessment Abbreviation used in this paper: 5-ALA = 5-aminolevulinic acid. of 5-ALA as a promising intraoperative adjunct for de- * Drs. Marbacher and Klinger contributed equally to this work. tecting nonglioblastoma high-grade glioma, low-grade Neurosurg Focus / Volume 36 / February 2014 1 Unauthenticated | Downloaded 09/29/21 05:12 PM UTC S. Marbacher et al. glioma, and meningioma tissue.5,43,45 More recently, a ret- standard examination protocol performed by a MAG- rospective study of 52 patients demonstrated that 62% of NETOM Espree 1.5-T or a MAGNETOM Avanto 1.5- brain metastases were positive for intraoperative 5-ALA T scanner (Siemens). The protocol consisted of regular fluorescence.20 5-mm diffusion-weighted imaging and susceptibility- Preliminary reports indicate that 5-ALA fluores- weighted imaging sequences, a 4-mm T2-weighted turbo cence increases the safety and accuracy of stereotactic spin echo sequence (TR/TE 6080 msec/96 msec), a 6-mm and endoscopic brain biopsy procedures.25,31,47 It has been T1-weighted spin echo sequence (TR/TE 450 msec/9.5 argued that speed and safety are increased by minimizing msec), and a true inversion recovery magnitude dark-fluid sampling errors.25,47 fat-saturated sequence (TR/TE 9000 msec/121 msec), Very few cases of adverse effects associated with use each in axial planes. Additionally, a contrast-enhanced of 5-ALA during glioma surgery have been reported. In a 0.9-mm T1-weighted volumetric interpolated breath- series of 74 patients the authors described adverse events hold examination high-resolution sequence (TR/TE 6.2 (phototoxic reaction, generalized edema) for only 2 pa- msec/2.38 msec) was performed in a sagittal direction, tients.14 The authors of large approval studies among 500 with multiplanar reformat workups in 1-mm axial and patients receiving 5-ALA before glioma resection have coronal planes. reported no adverse events associated with the drug.37,39 In accordance with the regulations of the European In this study, we analyzed our institutional experience Medicines Agency (www.ema.europa.eu/), 5-ALA was with 458 consecutive cases of primary brain tumors and administered only in the absence of any known history brain metastases treated either by microsurgical tumor of liver disease and signs of significant hepatic dysfunc- resection or biopsy after oral administration of 5-ALA. tion as seen clinically or determined by preoperative liver function tests. Further exclusion criteria for the adminis- Methods tration of 5-ALA were history of photosensitivity, patient or family history of porphyria, or pregnancy. An aqueous Patient Population and Data Acquisition solution of 5-ALA (Gliolan) was orally administered, at 20 mg/kg body weight, 3-5 hours before beginning the The study was supervised by the institutional review operation. board of our institution, Kantonsspital Aarau. The off-la- All open tumor resections were performed using bel use of 5-ALA for intracranial tumors was approved by standard microsurgical techniques and intraoperative the Swiss Agency for Therapeutic Products (Swissmedic). neuronavigation tools (StealthStation Treon, Medtronic, Informed consent for surgical treatment and administra- or VectorVision, Brainlab AG). Tumor biopsy samples tion of 5-ALA (Gliolan, medac GmbH) was obtained for were obtained stereotactically using frameless neuronavi- all patients. gation systems (BrainPro Titanium Biopsy Cannula Set, From February 2007 through December 2011, a to- PAJUNK GmbH) based on preoperative or intraoperative tal of 531 patients underwent 5-ALA–guided open resec- MRI scans (Polestar N20, Medtronic). tion or biopsy of primary brain tumors or metastases at For evaluation of 5-ALA fluorescence positivity, Kantonsspital Aarau. Of these, 458 patients fulfilled the blue-violet light was applied periodically during and at following inclusion criteria: 1) age 18 years or older, 2) the end of tumor resection or after biopsy samples were radiologically confirmed intracranial mass lesion, and 3) obtained (440-nm blue-violet light source, OPMI Pentero, consensus to either operate or perform a biopsy after case Carl Zeiss AG). To avoid phototoxic skin reactions from review by the hospital’s interdisciplinary neurooncology the sensitizing effect of protoporphyrin IX, patients re- tumor board. Clinical data were collected from patient mained in a dark environment for about 48 hours after charts, surgical consent forms, operative reports and in- surgery.9,21 traoperative video recordings, report forms on intraop- The formalin-fixed tissue specimens underwent stan- erative 5-ALA fluorescence, histology reports, discharge dard histological evaluation with H & E staining and im- summaries, and laboratory results. munohistochemical analysis at our institution. The following characteristics were further analyzed: Postoperatively, we discussed all patients at our inter- patient age, patient sex, histological diagnosis, tumor disciplinary neurooncology tumor board. Depending on location, intraoperative 5-ALA fluorescence positivity, age, histologicasl result, WHO tumor grade, clinical con- type of surgical procedure (open resection
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