Quantitative and qualitative 5-aminolevulinic acid-induced protoporphyrin IX fluorescence in skull base meningiomas - PubMed (original) (raw)
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Quantitative and qualitative 5-aminolevulinic acid-induced protoporphyrin IX fluorescence in skull base meningiomas
Kimon Bekelis et al. Neurosurg Focus. 2011 May.
Abstract
Object: Complete resection of skull base meningiomas provides patients with the best chance for a cure; however, surgery is frequently difficult given the proximity of lesions to vital structures, such as cranial nerves, major vessels, and venous sinuses. Accurate discrimination between tumor and normal tissue is crucial for optimal tumor resection. Qualitative assessment of protoporphyrin IX (PpIX) fluorescence following the exogenous administration of 5-aminolevulinic acid (ALA) has demonstrated utility in malignant glioma resection but limited use in meningiomas. Here the authors demonstrate the use of ALA-induced PpIX fluorescence guidance in resecting a skull base meningioma and elaborate on the advantages and disadvantages provided by both quantitative and qualitative fluorescence methodologies in skull base meningioma resection.
Methods: A 52-year-old patient with a sphenoid wing WHO Grade I meningioma underwent tumor resection as part of an institutional review board-approved prospective study of fluorescence-guided resection. A surgical microscope modified for fluorescence imaging was used for the qualitative assessment of visible fluorescence, and an intraoperative probe for in situ fluorescence detection was utilized for quantitative measurements of PpIX. The authors assessed the detection capabilities of both the qualitative and quantitative fluorescence approaches.
Results: The patient harboring a sphenoid wing meningioma with intraorbital extension underwent radical resection of the tumor with both visibly and nonvisibly fluorescent regions. The patient underwent a complete resection without any complications. Some areas of the tumor demonstrated visible fluorescence. The quantitative probe detected neoplastic tissue better than the qualitative modified surgical microscope. The intraoperative probe was particularly useful in areas that did not reveal visible fluorescence, and tissue from these areas was confirmed as tumor following histopathological analysis.
Conclusions: Fluorescence-guided resection may be a useful adjunct in the resection of skull base meningiomas. The use of a quantitative intraoperative probe to detect PpIX concentration allows more accurate determination of neoplastic tissue in meningiomas than visible fluorescence and is readily applicable in areas, such as the skull base, where complete resection is critical but difficult because of the vital structures surrounding the pathology.
Conflict of interest statement
Disclosure: The authors report no conflict of interest concerning the materials or methods used in this study or the findings specified in this paper.
Figures
Fig. 1
Qualitative and quantitative ALA-induced PpIX fluorescence–guided resection images. Fluorescence-guided resection of a skull base meningioma showed varying levels of qualitative and quantitative fluorescence. A histologically confirmed tumor region with large amounts of accumulated PpIX showing high levels of visible fluorescence under blue light excitation (A) with the corresponding white light image (B), and the quantitative fluorescence spectrum (C) showing the distinctive PpIX spectrum. A region of normal dura showed no visible fluorescence under blue light excitation (D) with the corresponding white light image (E), and the quantitative fluorescence spectrum (F) showed no PpIX peaks, only a distinctive autofluorescence spectrum.
Fig. 2
Protoporphyrin IX concentrations in skull base meningioma. Scatter plot of PpIX concentrations in normal and tumor tissue (mean 4.81 ± 1.49 μg/ml, range 0.11–19.15 μg/ml). Tumor tissue accumulated significantly more PpIX than normal tissue. Concentrations in normal dura were all below the level of quantification and outside the axis limits.
Comment in
- 5-Aminolevulinic acid-guided resection of bone-invasive meningiomas.
Della Puppa A, Scienza R. Della Puppa A, et al. Neurosurg Focus. 2013 Oct;35(4):E6. doi: 10.3171/2012.6.FOCUS12236. Neurosurg Focus. 2013. PMID: 24079785 No abstract available. - Response.
Bekelis K, Roberts DW. Bekelis K, et al. Neurosurg Focus. 2013 Oct;35(4):E6. Neurosurg Focus. 2013. PMID: 24205519 No abstract available.
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