Abstract
(1) Background: Gangliogliomas comprise a small number of brain tumors. They usually present as World Health Organization (WHO) grade I, and they delineate on gadolinium-enhanced MRI; the surgical goal is wide radical resection, and the course thereafter is usually benign. Fluorescein sodium (FL) tends to accumulate in areas with altered blood–brain barrier (BBB). Thus far, the results provided by prospective and retrospective studies show that the utilization of this fluorophore may be associated with better visualization and improvement of resection for several tumors of the central nervous system. In this study, we retrospectively studied the effect of fluorescein sodium on visualization and resection of gangliogliomas. (2) Methods: Surgical databases in three neurosurgical departments (Regensburg University Hospital; Besta Institute, Milano, Italy; and Liv Hospital, Istanbul, Turkey), with approval by the local ethics committee, were retrospectively reviewed to find gangliogliomas surgically removed by a fluorescein-guided technique by the aid of a dedicated filter on the surgical microscope from April 2014 to February 2020. Eighteen patients (13 women, 5 men; mean age 22.9 years, range 3 to 78 years) underwent surgical treatment for gangliogliomas during 19 operations. Fluorescein was intravenously injected (5 mg/kg) after general anesthesia induction. Tumors were removed using a microsurgical technique with the YELLOW 560 Filter (YE560) (KINEVO/PENTERO 900, Carl Zeiss Meditec, Oberkochen, Germany). (3) Results: No side effects related to fluorescein occurred. In all tumors, contrast enhancement on preoperative MRI correlated with bright yellow fluorescence during the surgical procedure (17 gangliogliomas WHO grade I, 1 ganglioglioma WHO grade II). Fluorescein was considered helpful by the operating surgeon in distinguishing tumors from viable tissue in all cases (100%). Biopsy was intended in two operations, and subtotal resection was intended in one operation. In all other operations considered preoperatively eligible, gross total resection (GTR) was achieved in 12 out of 16 (75%) instances. (4) Conclusions: The use of FL and YE560 is a readily available method for safe fluorescence-guided tumor resection, possibly visualizing tumor margins intraoperatively similar to contrast enhancement in T1-weighted MRI. Our data suggested a positive effect of fluorescein-guided surgery on intraoperative visualization and extent of resection during resection of gangliogliomas.
Highlights
Gangliogliomas comprise a small number of brain tumors [1]
In all cases but one (Pat. 8), intraoperative fluorescence was deemed helpful for improved resection
In three patients (Pat. 13, 17, and 18), gross total resection (GTR) was deemed possible according to the preoperative magnetic resonance imaging (MRI), but intraoperative constraints limited the extent of resection (EOR)
Summary
Gangliogliomas comprise a small number of brain tumors [1]. They are composed of ganglion cells (neurons) and glial (astrocytic) cells, and according to predominance, they are classified into ganglioneuromas and gangliogliomas. Near-infrared optical imaging in one study could visualize tumors with preoperative gadolinium enhancement on MRI [16]. Because even single perivascular glioma cells disrupt the BBB [25,26], it stands to reason that this effect could improve glioma resection The safety of this fluorophore has been demonstrated with more than 40 years of experience in ophthalmology, a field where it is used as a vascular dye [27]. We present an alternative technique to localize and examine gangliogliomas intraoperatively, guiding tumor resection, using FL and an FL-specific microscope filter. This multicenter study, to our knowledge, is the first report on the effect of FL on visualization and resection of ganglioglioma
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