Aggressive resection at the infiltrative margins of glioblastoma facilitated by intraoperative fluorescein guidance.

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2017
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Abstract
OBJECTIVE Extent of resection is an important prognostic factor in patients undergoing surgery for glioblastoma (GBM). Recent evidence suggests that intravenously administered fluorescein sodium associates with tumor tissue, facilitating safe maximal resection of GBM. In this study, the authors evaluate the safety and utility of intraoperative fluorescein guidance for the prediction of histopathological alteration both in the contrast-enhancing (CE) regions, where this relationship has been established, and into the non-CE (NCE), diffusely infiltrated margins. METHODS Thirty-two patients received fluorescein sodium (3 mg/kg) intravenously prior to resection. Fluorescence was intraoperatively visualized using a Zeiss Pentero surgical microscope equipped with a YELLOW 560 filter. Stereotactically localized biopsy specimens were acquired from CE and NCE regions based on preoperative MRI in conjunction with neuronavigation. The fluorescence intensity of these specimens was subjectively classified in real time with subsequent quantitative image analysis, histopathological evaluation of localized biopsy specimens, and radiological volumetric assessment of the extent of resection. RESULTS Bright fluorescence was observed in all GBMs and localized to the CE regions and portions of the NCE margins of the tumors, thus serving as a visual guide during resection. Gross-total resection (GTR) was achieved in 84% of the patients with an average resected volume of 95%, and this rate was higher among patients for whom GTR was the surgical goal (GTR achieved in 93.1% of patients, average resected volume of 99.7%). Intraoperative fluorescein staining correlated with histopathological alteration in both CE and NCE regions, with positive predictive values by subjective fluorescence evaluation greater than 96% in NCE regions. CONCLUSIONS Intraoperative administration of fluorescein provides an easily visualized marker for glioma pathology in both CE and NCE regions of GBM. These findings support the use of fluorescein as a microsurgical adjunct for guiding GBM resection to facilitate safe maximal removal.
Reference Key
neira2017aggressivejournal Use this key to autocite in the manuscript while using SciMatic Manuscript Manager or Thesis Manager
Authors Justin A Neira, Timothy H Ung, Jennifer S Sims, Hani R Malone, Daniel S Chow, Jorge L Samanamud, George J Zanazzi, Xiaotao Guo, Stephen G Bowden, Binsheng Zhao, Sameer A Sheth, Guy M McKhann, Michael B Sisti, Peter Canoll, Randy S D'Amico, Jeffrey N Bruce
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Journal journal of neurosurgery
Year 2017
DOI
10.3171/2016.7.JNS16232
URL
Keywords
glioblastoma gbm = glioblastoma roi = region of interest oncology pfs = progression-free survival eor = extent of resection gtr = gross-total resection os = overall survival str = subtotal resection 5-ala = 5-aminolevulinic acid bbb = blood-brain barrier ce = contrast enhancing cumc = columbia university medical center hgg = high-grade glioma nce = non–contrast enhancing ppv = positive predictive value ud = undetermined who = world health organization y560 = yellow 560 fluorescein fluorescence-guidance fluorescence-guided resection high-grade glioma n-anova = multiway anova

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