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Intraoperative confocal laser endomicroscopy during 5-aminolevulinic acid-guided glioma surgery: significant
Irakliy Abramov1, Andrea M Mathis2, Yuan Xu1
11Department of Neurosurgery, The Loyal and Edith Davis Neurosurgical Research Laboratory, St. Joseph's Hospital and Medical Center, Barrow Neurological Institute, Phoenix, Arizona.
Objective:
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.
Methods:
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.
Results:
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.
Conclusions:
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.
Insights
Fluorescein sodium confocal laser endomicroscopy (CLE) offers better glioma margin detection than 5-aminolevulinic acid (5-ALA) fluorescence imaging. This advanced technique aids neurosurgeons in achieving maximal safe resection by improving tumor boundary visualization.
Area of Science:
- Neurosurgery
- Oncology
- Medical Imaging
Background:
- Gliomas present challenges in maximal safe resection due to poorly defined tumor margins.
- Fluorescence-guided surgery aids in discerning tumor boundaries for improved resection.
- Confocal laser endomicroscopy (CLE) and 5-aminolevulinic acid (5-ALA) are fluorescence techniques used in glioma surgery.
Purpose of the Study:
- To evaluate the simultaneous use of fluorescein sodium (FNa) CLE and 5-ALA fluorescence imaging.
- To assess the efficacy of FNa CLE in improving margin discrimination during glioma resection.
- To compare the accuracy of FNa CLE and 5-ALA imaging in identifying infiltrating glioma.
Main Methods:
- FNa CLE and 5-ALA wide-field imaging were performed in 33 glioma patients.
- CLE imaging was enhanced by a telesurgical pathology software platform for real-time surgeon-pathologist communication.
- Tissue biopsies were taken at imaging locations, and interpretations were compared with permanent histological sections.
Main Results:
- FNa CLE identified infiltrative glioma regions that typically lacked 5-ALA fluorescence.
- FNa CLE interpretation showed higher concordance with histology (65%) compared to 5-ALA imaging (49%).
- FNa CLE demonstrated higher sensitivity (73%) and positive predictive value (79%) for tumor margins than 5-ALA.
Conclusions:
- Conventional intraoperative evaluation can underestimate glioma invasiveness.
- FNa CLE exhibits superior accuracy in detecting infiltrating tumor regions compared to 5-ALA imaging.
- Further studies with larger cohorts are recommended for rigorous comparison of FNa CLE and 5-ALA guided resections.
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