5-Aminolevulinic acid-induced protoporphyrin IX fluorescence as immediate intraoperative indicator to improve the safety of malignant or high-grade brain tumor diagnosis in frameless stereotactic biopsies

Gord Von Campe,Michael Moschopulos,Martin Hefti

doi:10.1007/s00701-012-1290-8

Gord Von Campe, Michael Moschopulos + Show 1 more

Open Access

https://doi.org/10.1007/s00701-012-1290-8

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Abstract

BackgroundFrameless stereotactic biopsies are replacing frame-based stereotaxy as a diagnostic approach to brain lesions. In order to avoid a sampling bias or negative histology, multiple specimens are often taken. This in turn increases the risk of hemorrhagic complications.ObjectiveWe present the use of 5-aminolevulinic acid (5-ALA)-induced protoporphyrin IX fluorescence in frameless stereotaxy to improve the procedure duration and yield, and thereby reduce the risk of complications.MethodsPatients with suspected high-grade brain tumors are given 5-ALA 4 h prior to stereotactic biopsy. The biopsy needle is guided to the target using frameless stereotaxy based either on preoperative images or combined with intraoperative MRI sequences. The specimen is illuminated with blue light to look for fluorescence. In case of a positive fluorescence within the tissue sample, no frozen sections are obtained, and no further specimens are taken.ResultsThe samples of 13 patients revealed a positive fluorescence and were histologically confirmed as malignant or high-grade brain neoplasms. four cases were fluorescence-negative, requiring frozen section confirmation and/or multiple samples. In theses cases histology was either nonspecific gliotic changes or low-grade tumors. There were no complications related to the additional use of 5-ALA.Conclusion5-ALA fluorescence in stereotactic biopsies can increase the safety and accuracy of these procedures by reducing sampling errors and eliminating the need for multiple samples and/or frozen section verification, creating a more accurate, faster and safer procedure for cases of suspected malignant or high-grade brain tumors situated in deep or eloquent areas.

Highlights

Over the last few years, frameless stereotactic biopsies have progressively replaced frame-based stereotactic procedures as a first line diagnostic approach to various brain lesions
After removal of the needle it is placed under a 405–440-nm blue light source with the specimen still in place to look for fluorescence
We used intraoperative MR imaging (PoleStar N20®, Medtronic, Yokneam Elit, Israel) for navigation to assess the accuracy of the method described and to rule-out an acute hemorrhagic complication, the same methodology is applicable to frameless stereotactic procedures based on preoperative CT or MR images, the main purpose being that no further samplings are required in case of a positive fluorescence

Summary

Introduction

Over the last few years, frameless stereotactic biopsies have progressively replaced frame-based stereotactic procedures as a first line diagnostic approach to various brain lesions. In cases where the frameless stereotactic biopsy is based solely on preoperative computertomographic (CT) or MRI images, the results are even less favorable with 37% [1] to 49% [5] of incorrectly diagnosed gliomas. In order to avoid sampling bias, obtaining multiple specimens has been advocated [12]. Frameless stereotactic biopsies are replacing frame-based stereotaxy as a diagnostic approach to brain lesions. In order to avoid a sampling bias or negative histology, multiple specimens are often taken. This in turn increases the risk of hemorrhagic complications

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