Tumour Infiltration Zone Research Articles

TMIC-45. DISTRIBUTION AND TUMOR CELL PROXIMITY OF IMMUNE CELLS IN THE TUMOR CORE, INFILTRATION ZONE AND PERIPHERY OF GLIOBLASTOMAS

Abstract Glioblastoma is the most frequent and malignant brain tumor. Immune therapies have had limited effect, but not much is known about the frequency and type of immune cells in the infiltration zone and periphery. In these areas, tumor cells migrate into the brain parenchyma and prevent total tumor resection thereby leading to recurrence. This study aims to quantify the type and distribution of immune cells in glioblastomas. A cohort of 67 glioblastomas was established containing tissue from central tumor and/or infiltration zone and/or tumor periphery. Patients were included if most tumor cells were positive in immunohistochemical staining for P53. A multiplex staining was established, where tissue sections were stained with P53 (tumor cells), FOXP3 (FOXP3+ regulatory T cells), CD8 (CD8+ cytotoxic T cells) and IBA1 (microglia/macrophages). Cells were counted in tumor core, infiltration zone and periphery using Visiopharm software based on training of convolutional neural networks. Moreover, the number of tumor cells with immune cells in proximity (30 µm) was quantified. The number of CD8+, FOXP3+ and Iba1+ cells was significantly higher in the core than in the periphery (P < 0.001), and in the infiltration zone than in the periphery (P < 0.001). However, the CD8+, FOXP3+ and Iba1+ cells/tumor cell ratio increased from core to infiltration zone and to periphery (P < 0.001). There was a higher amount of tumor cells with CD8+ cells in proximity in the tumor core (P < 0.001), whereas the highest amount of tumor cells with IBA1+ cells and FOXP3+ cells in proximity was the infiltration zone (P < 0.001). In conclusion, although levels of immune cells are highest in the tumor core - the higher proximity and ratio of immune cells to tumor cells in the infiltration zone/periphery suggest immune-suppressive mechanisms to be active in these areas.

Quantitative proteomic landscapes of primary and recurrent glioblastoma reveal a protumorigeneic role for FBXO2-dependent glioma-microenvironment interactions.

Recent efforts have described the evolution of glioblastoma from initial diagnosis to post-treatment recurrence on a genomic and transcriptomic level. However, the evolution of the proteomic landscape is largely unknown. Sequential window acquisition of all theoretical fragment ion spectra mass spectrometry (SWATH-MS) was used to characterize the quantitative proteomes of two independent cohorts of paired newly diagnosed and recurrent glioblastomas. Recurrence-associated proteins were validated using immunohistochemistry and further studied in human glioma cell lines, orthotopic xenograft models, and human organotypic brain slice cultures. External spatial transcriptomic, single-cell, and bulk RNA sequencing data were analyzed to gain mechanistic insights. Although overall proteomic changes were heterogeneous across patients, we identified BCAS1, INF2, and FBXO2 as consistently upregulated proteins at recurrence and validated these using immunohistochemistry. Knockout of FBXO2 in human glioma cells conferred a strong survival benefit in orthotopic xenograft mouse models and reduced invasive growth in organotypic brain slice cultures. In glioblastoma patient samples, FBXO2 expression was enriched in the tumor infiltration zone and FBXO2-positive cancer cells were associated with synaptic signaling processes. These findings demonstrate a potential role of FBXO2-dependent glioma-microenvironment interactions to promote tumor growth. Furthermore, the published datasets provide a valuable resource for further studies.

Cerebrospinal fluid cytokine levels are associated with macrophage infiltration into tumor tissues of glioma patients

BackgroundDiffuse gliomas are the most common malignant tumors of the central nervous system with poor treatment efficacy. Infiltration of immune cells into tumors during immunosurveillance is observed in multiple tumor entities and often associated with a favorable outcome. The aim of this study was to evaluate the infiltration of immune cells in gliomas and their association with cerebrospinal fluid (CSF) cytokine concentrations.MethodsWe applied immunohistochemistry in tumor tissue sections of 18 high-grade glioma (HGG) patients (4 anaplastic astrocytoma, IDH-wildtype WHO-III; 14 glioblastomas (GBM), IDH-wildtype WHO-IV) in order to assess and quantify leucocytes (CD45) and macrophages (CD68, CD163) within the tumor core, infiltration zone and perivascular spaces. In addition, we quantified the concentrations of 30 cytokines in the same patients’ CSF and in 14 non-inflammatory controls.ResultsWe observed a significantly higher percentage of CD68+ macrophages (21–27%) in all examined tumor areas when compared to CD45+ leucocytes (ca. 3–7%); CD163+ cell infiltration was between 5 and 15%. Compared to the tumor core, significantly more macrophages and leucocytes were detectable within the perivascular area. The brain parenchyma showing a lower tumor cell density seems to be less infiltrated by macrophages. Interleukin (IL)-7 was significantly downregulated in CSF of GBM patients compared to controls. Additionally, CD68+ macrophage infiltrates showed significant correlations with the expression of eotaxin, interferon-γ, IL-1β, IL-2, IL-10, IL-13, IL-16 and vascular endothelial growth factor.ConclusionsOur findings suggest that the infiltration of lymphocytes is generally low in HGG, and does not correlate with cytokine concentrations in the CSF. In contrast, macrophage infiltrates in HGG are associated with CSF cytokine changes that possibly shape the tumor microenvironment. Although results point towards an escape from immunosurveillance or even exploitation of immune cells by HGG, further studies are necessary to decipher the exact role of the immune system in these tumors.

OTME-13. Integration of metabolic and transcriptional signatures of glioblastoma invasion reveals extracellular matrix reorganization and vasculature remodeling

BackgroundThe invasive behavior of glioblastoma is considered highly relevant for recurrence. However, the invasion zone is difficult to visualize, typically lies outside the resected and irradiated area, and is protected by the blood brain barrier, posing a particular challenge for treatment. We present biological features of invasive growth accompanying tumor progression and invasion based on associated metabolic and transcriptomic changes in patient derived orthotopic xenografts (PDOX) and corresponding patients.MethodsPatients with suspected glioblastoma were enrolled (NCT02904525) and underwent 1H-MR spectroscopy and imaging (1H-MRS/I, 7T). Tissue obtained at surgery was transplanted orthotopically into immune-compromised mice. Longitudinal follow-up was performed by 1H-MRS/I (14.1T) on the injected and the contralateral side. The PDOX, the corresponding contralateral side, and the original human tumors underwent RNA-sequencing.ResultsThe temporal changes of the metabolite profiles characterized the kinetics of invasive growth of PDOX, and were patient specific. Comparison of 1H-MRS derived metabolite signatures, reflecting temporal changes of tumor development and invasion in PDOX, revealed high similarity to spatial metabolite signatures of combined multi-voxel analyses of the patients’ tumors. Associations between the metabolite profiles and the combined transcriptome of the xenografts and the host, reflected molecular signatures of invasion, comprising extracellular matrix degradation and reorganization, growth factor binding, and vascular remodeling.ConclusionIntegrating metabolic profiles and gene expression of highly invasive PDOX allows in vivo monitoring of progression in the non-enhancing tumor infiltration zone and provides insights into the remodeling of the extracellular matrix that is essential for cell-cell communication and regulation of cellular processes. The changes of the structural and biochemical properties of the extracellular matrix are of importance for the biological behavior of the tumors and may be subjected to therapeutic targeting.

Glial regenerative cell types in the superficial cortex in cortical dysplasia subtypes

PurposeFocal Cortical Dysplasias (FCD) are localized malformative brain lesions in epilepsy. FCD3a associated with hippocampal sclerosis, affects the superficial cortex and is presumed to have an ‘acquired’ rather than developmental origin. Precursor cells may arise outside neurogenic zones including cortical layer I. Our aim was to characterise subsets of glial progenitor cells in the superficial cortical layers, known to be involved in gliosis and gliogenesis and that could distinguish FCD3a from other subtypes. MethodsUsing immunohistochemistry we quantified the density of glial progenitor subsets in superficial cortex layers using markers against PAX6, GFAP, Olig2 and PDGFRβ and proliferation marker MCM2 in ten FCD3a cases compared to 18 other FCD types and 11 non-FCD controls. Key findingsGlial progenitor cells types were present in the cortical layer I and II in all FCD groups. GFAP cells frequently expressed PAX6 and significantly higher GFAP/PAX6 than GFAP/MCM2 cell densities were identified in the FCD3a group (p < 0.05). Olig2 cell densities were significantly higher in FCD3b than FCD3a (p = 0.002) and significantly higher GFAP/MCM2 compared to PDGFRβ/MCM2 cell densities were identified in both FCD3b and FCD2 groups. There was no correlation between cell densities and the age of patients at surgery and between cortical regions. SignificanceImmature and proliferative glial populations across FCD variants reflect reactive cell types and differences may provide insight into underlying pathomechanisms. Higher PAX6 expression in astroglial cells in FCD3a may indicate a switch to astrocytic maturation and enhanced superficial gliosis. Higher Olig2 and GFAP/MCM2 densities in FCD3b may reflect margins of the tumour infiltration zone rather than true cortical dysplasia.

Selective, high-contrast detection of syngeneic glioblastoma in vivo

Glioblastoma is a highly malignant, largely therapy-resistant brain tumour. Deep infiltration of brain tissue by neoplastic cells represents the key problem of diffuse glioma. Much current research focuses on the molecular makeup of the visible tumour mass rather than the cellular interactions in the surrounding brain tissue infiltrated by the invasive glioma cells that cause the tumour’s ultimately lethal outcome. Diagnostic neuroimaging that enables the direct in vivo observation of the tumour infiltration zone and the local host tissue responses at a preclinical stage are important for the development of more effective glioma treatments. Here, we report an animal model that allows high-contrast imaging of wild-type glioma cells by positron emission tomography (PET) using [18 F]PBR111, a selective radioligand for the mitochondrial 18 kDa Translocator Protein (TSPO), in the Tspo−/− mouse strain (C57BL/6-Tspotm1GuMu(GuwiyangWurra)). The high selectivity of [18 F]PBR111 for the TSPO combined with the exclusive expression of TSPO in glioma cells infiltrating into null-background host tissue free of any TSPO expression, makes it possible, for the first time, to unequivocally and with uniquely high biological contrast identify peri-tumoral glioma cell invasion at preclinical stages in vivo. Comparison of the in vivo imaging signal from wild-type glioma cells in a null background with the signal in a wild-type host tissue, where the tumour induces the expected TSPO expression in the host’s glial cells, illustrates the substantial extent of the peritumoral host response to the growing tumour. The syngeneic tumour (TSPO+/+) in null background (TSPO−/−) model is thus well suited to study the interaction of the tumour front with the peri-tumoral tissue, and the experimental evaluation of new therapeutic approaches targeting the invasive behaviour of glioblastoma.

Hemodynamic investigation of peritumoral impaired blood oxygenation-level dependent cerebrovascular reactivity in patients with diffuse glioma

IntroductionThe presence of peritumorally impaired blood oxygenation-level dependent cerebrovascular reactivity (BOLD-CVR) has been unequivocally demonstrated in patients with diffuse glioma, and may have value to better identify tumor infiltration zone. Since BOLD-CVR does not measure hemodynamic changes directly, we performed additional MR perfusion studies to better characterize the peritumoral hemodynamic environment. MethodsSeventeen patients with WHO grade III and IV diffuse glioma underwent high resolution advanced hemodynamic MR imaging including BOLD-CVR and MR perfusion. The obtained multiparametric hemodynamic factors (i.e., regional cerebral blood flow (rCBF), relative cerebral blood volume (rCBV), mean transit time (MTT), time-to-peak (TTP) and BOLD-CVR, were analyzed within 10 concentric expanding 3 mm volumes of interest (VOIs) up to 30 mm from the tumor tissue mask. ResultsBOLD-CVR impairment was found within the tumor tissue mask and the peritumoral VOIs up to 21 mm as compared to the contralateral flipped CVR analysis (p<0.05). In the affected hemisphere, we observed positive spatial correlations including all VOIs between BOLD-CVR and rCBV values (r=0.27; p<0.001), rCBF (r=0.42; p<0.001) and a negative correlation between BOLD-CVR and TTP (r=-0.47; p<0.001). ConclusionsPeritumorally impaired BOLD-CVR is associated with concomitant hemodynamic alterations with severity correlating to tumor volume. The distribution of these multiparametric hemodynamic MRI patterns may be considered for future studies characterizing the hemodynamic peritumoral environment, thereby better identifying the extent of tumor infiltration.

Upregulation of CD20 Positive B-Cells and B-Cell Aggregates in the Tumor Infiltration Zone is Associated with Better Survival of Patients with Pancreatic Ductal Adenocarcinoma.

Patients with pancreatic ductal adenocarcinoma (PDAC) normally have a poor long-term prognosis. However, some rare cases of long-term survivors have been reported. The tumor microenvironment, consisting of cellular and stromal components, possibly plays an important role and might influence prognosis. In this context, the role of tumor-infiltrating B-cells and its impact on the survival in patients with PDAC remains controversial. We therefore aimed to assess the prognostic value of CD20-positive B-cells and CD20-positive B-cell aggregates as well as CD138, IgM, Pax5, and Ki67 on the survival of patients with PDAC using immunohistochemistry of FFPE pancreatectomy tissue sections from patients that underwent primary surgery for pT3- and R0-pancreatic adenocarcinoma between 1995 and 2016. Patients with PDAC were matched and grouped in 16 long-term-survivors (LTS, median overall survival (OS): 96 months [range: 61–177 months]) and 16 short-term-survivors (STS, median OS: 16 months [range: 7–32 months]). CD20-positive B-cells and B-cell aggregates in the tumor infiltration zone were significantly upregulated in the LTS-group compared to the STS-group (p = 0.0499 respectively p = 0.0432). Regarding the entire patient cohort (n = 32) CD20 positive B-cell aggregates in the tumor infiltration zone were an independent prognostic marker for overall survival in multivariate analysis (HR 9.2, CI 1.6–51.4, p = 0.012). These results underline the importance of tumor-associated B-cells for prognosis of patients with PDAC. The detailed role of B cells in the pathomechanism of PDAC should be further investigated for predicting outcome, identifying appropriate treatment regimens, and developing novel therapeutic options.

TMIC-09. MULTIMODAL VISIBLE LIGHT OPTICAL COHERENCE MICROSCOPY AND FLUORESCENCE IMAGING OF GLIOBLASTOMA REGIONAL SAMPLES

Abstract Optical coherence tomography (OCT) is an imaging modality based on the inherent backscattering of light within different tissue types. OCT was introduced in the early 1990s and has since become a standard diagnostic tool in ophthalmology. Images can be acquired non-destructively, in real time and three dimensions at micrometer resolution. Only recently, OCT has been increasingly recognized in other fields such as neuroimaging. Here we present a multimodal imaging approach using a custom-built visible light optical coherence microscope (OCM) combined with a fluorescence imaging mode for the evaluation of different tumor compartments in glioblastoma (GB) samples retrieved during 5-aminolevulinic acid (5-ALA) fluorescence-guided surgery. 18 biopsies of ten GB patients were imaged using the visible light OCM system, providing the three-dimensional morphologic structure of the tissue on a cellular level (axial resolution in brain tissue 0.88 µm, penetration depth 100 µm). Attenuation coefficients, i.e., indicators for light penetration and scattering, were calculated for each sample. Tumor-specific contrast enhanced by 5-ALA was evaluated in co-registered images from the fluorescence channel. Samples were ultimately processed for histopathologic work-up and compared to OCM findings. Three different groups of biopsies could be defined based on quantitative 5-ALA fluorescence [normalized between 0 and 1], attenuation [mm-1] and histological H&amp;E stainings: tumor core (n=8; fluorescence [median ± standard deviation]=0.72±0.13, attenuation [median ± standard deviation]=3.9±0.66), infiltration zone (n=6; fluorescence=0.5±0.19, attenuation=4.4±0.5), and adjacent brain parenchyma (n=4; fluorescence=0.3±0.12, attenuation=5.0±0.79). Concurrent increase in fluorescence intensity and cell density was significantly associated with tissue malignancy (tumor core: 3849±1028 nuclei/mm²; brain parenchyma: 1364±236 nuclei/mm². p=0.024). Furthermore, a negative correlation between fluorescence and attenuation coefficient was detected (r=0.51, p=0.032). Aforementioned results suggest that this multimodal imaging setup is a promising approach for non-destructively investigating the three-dimensional morphologic structure at microscopic resolution whilst at the same time leveraging tumor-specific contrast through 5-ALA fluorescence.

Low-grade (WHO II) and anaplastic (WHO III) gliomas: differences in morphology and MRI signal intensities

To evaluate the diagnostic potential of a multi-factor analysis of morphometric parameters and signal characteristics of brain tumours and peritumoural areas for distinguishing WHO-grade II and III gliomas at magnetic resonance imaging (MRI). MR examinations of 108 patients with histologically proven World Health Organization (WHO) grade II and III gliomas were included. Morphological criteria and MR signal characteristics were evaluated. The data were subjected to a multifactorial logistic regression analysis to differentiate between grade II and grade III gliomas. The discriminatory power was assessed by receiver operating characteristic (ROC). Logistic regression analysis showed that WHO grade II and III can be distinguished based on contrast enhancement, cortical involvement, margin of the enhancing lesion and maximum diameter (width and length) of the peritumoural area (the so-called tumour infiltration zone). With the final model of logistic regression analysis and with the cut-off value ≥ 0.377, WHO grade III glioma is predicted with a sensitivity of 71.0 % and a specificity of 80.4 %. Measurement of maximum diameter of peritumoural area, contrast enhancement as well as cortical involvement and the margin of the contrast-enhancing lesion can be used easily in clinical routine to adequately distinguish WHO grade II from grade III gliomas. • MRI offers new information concerning WHO-grade II and III gliomas. • The differentiation between such tumour grades is important for therapeutic decisions. • We assessed differences in enhancement, cortical involvement, margins and peritumoural appearances. • WHO grade III gliomas can be predicted with reasonable sensitivity and specificity.

Confocal Neurolasermicroscopy in Human Brain – Perspectives for Neurosurgery on a Cellular Level (including additional Comments to this article)

During neurosurgery intraoperative imaging of vital neural structures on a cellular level would facilitate the development of new strategies for diagnosis and treatment. In vivo imaging would permit the detection of the tumour centre and infiltration zone. With targeted biopsies the lesion of interest could be determined before performing the biopsy, facilitating the final pathological diagnosis. In this study we present confocal neurolasermicroscopy as a new method in neurosurgery. A miniaturised confocal neurolasermicroscope (NLM) was used ex vivo immediately after tumour resection of glioblastoma multiforme (GBM). NLM was performed with subcellular magnification up to a tissue depth of 100 microm. NLM images were compared to conventional histological images of the same tumour. The application of the method in nine patients allowed adequate diagnosis of a malignant glioma fulfilling the WHO criteria when compared to conventional histology. In one patient with glioblastoma multiforme NLM allowed the correct diagnosis of GBM to be made, demonstrating the high mitotic rate and cell pleomorphy of the tumour cells. Additional characteristics such as pleomorphic cells, mitotic figures, fibrillary matrix and the distinction between tumour centre and infiltration zone could be shown. NLM is a tool which could be adapted for neurosurgical intraoperative applications with the potential to diagnose tumours and recognise the tumour centre and infiltration zone in vivo. Further applications of NLM to characterise subcellular structures and vascular architecture are possible.

Proton Magnetic Resonance Spectroscopic Imaging Integrated into Image-guided Surgery: Correlation to Standard Magnetic Resonance Imaging and Tumor Cell Density

In this study, we attempted to improve the delineation of the infiltration zone in gliomas using proton magnetic resonance spectroscopic imaging (1H MRSI). In conventional magnetic resonance imaging (MRI), the boundaries of gliomas sometimes are underestimated. 1H MRSI is a noninvasive tool that can be used to investigate the spatial distribution of metabolic changes in brain lesions. The purpose was to correlate tumor cell density from histopathological specimens with metabolic levels and the coregistered metabolic maps. We developed a method to integrate spectroscopic data depicted as metabolic maps of biochemically pathological tissue into frameless stereotaxy. In seven patients harboring gliomas, we performed 1H MRSI with high spatial resolution and evaluated the spectral data. An algorithm was developed for user-independent calculation of pathological voxels and for visualization as metabolic maps. These maps were integrated into a three-dimensional MRI data set used for frameless stereotaxy. Stereotactic biopsies were taken from three different areas in and around the tumor involving the maximum pathological change, the border zone, and an area from outside the spectroscopically suspicious area. These specimens were correlated to the exact voxel positions in the stereotactic image space and evaluated histopathologically. In all cases, the implementation of the metabolic maps into frameless stereotaxy was successful, and stereotactic biopsies were acquired by use of the spectral data. A relation could be demonstrated between the metabolic changes and tumor cell density ranging from 60 to 100% in the maximum pathological area to 5 to 15% in the border zone. Interestingly, the tumor areas defined by the metabolic maps and histopathologically confirmed by biopsy exceeded the T2-weighted signal change in all cases, ranging from 6 to 32% in the examined volume. Our preliminary data suggest that 1H MRSI may be useful in combination with frameless stereotaxy to define more exactly the tumor infiltration zone in glioma surgery compared with conventional anatomic MRI alone.

Spectroscopy and Navigation

Object. It is often difficult to delineate the extent of invasion of high- and low-grade gliomas into normal brain tissue by using conventional T 1 - and T 2 -weighted magnetic resonance (MR) imaging. Knowledge of the relationship between the tumor infiltration zone and normal brain, however, is one of the prerequisites for performing as radical a tumor resection as possible. Proton MR spectroscopy allows noninvasive measurements of the concentrations and spatial distributions of brain metabolites and, therefore, may provide biochemical information in vivo, that is useful in distinguishing pathological from normal areas of the brain. The authors have developed a method to use the properties of MR spectroscopy to investigate intraoperatively pathological changes in the spatial distribution of choline (Cho)-containing compounds, total creatine, and N-acetyl-aspartate (NAA) in brain tumors with the aid of frameless stereotaxy. Methods. Maps of the Cho/NAA ratio were calculated and automatic segmentation of the tumors was performed. Spectroscopic images of the segmented tumor were matched to an anatomical three-dimensional (3D) MR imaging set by applying a fully automated mutual-information algorithm. The resulting 3D MR image can be used subsequently for neurosurgical planning, transfer to a frameless stereotactic system, and display in the navigation microscope during surgery leading to 1 H-MR spectroscopy-guided navigation. Conclusions. This method may allow better intraoperative identification of tumor border zones based on metabolic changes due to tumor infiltration.

Integration of biochemical images of a tumor into frameless stereotaxy achieved using a magnetic resonance imaging/magnetic resonance spectroscopy hybrid data set.

It is often difficult to delineate the extent of invasion of high- and low-grade gliomas into normal brain tissue by using conventional T1- and T2-weighted magnetic resonance (MR) imaging. Knowledge of the relationship between the tumor infiltration zone and normal brain, however, is one of the prerequisites for performing as radical a tumor resection as possible. Proton MR spectroscopy allows noninvasive measurements of the concentrations and spatial distributions of brain metabolites and, therefore, may provide biochemical information in vivo, that is useful in distinguishing pathological from normal areas of the brain. The authors have developed a method to use the properties of MR spectroscopy to investigate intraoperatively pathological changes in the spatial distribution of choline (Cho)-containing compounds, total creatine, and N-acetylaspartate (NAA) in brain tumors with the aid of frameless stereotaxy. Maps of the Cho/NAA ratio were calculated and automatic segmentation of the tumors was performed. Spectroscopic images of the segmented tumor were matched to an anatomical three-dimensional (3D) MR imaging set by applying a fully automated mutual-information algorithm. The resulting 3D MR image can be used subsequently for neurosurgical planning, transfer to a frameless stereotactic system, and display in the navigation microscope during surgery leading to 1H-MR spectroscopy-guided navigation. This method may allow better intraoperative identification of tumor border zones based on metabolic changes due to tumor infiltration.

Integration of MR spectroscopy into neuronavigation for stereotactic definition of tumor infiltration zone

BACKGROUNDTumor removal, brain swelling, the use of brain retractors, and cerebrospinal-fluid drainage all result in an intraoperative brain deformation that is known as brain shift. Thus, neuronavigation systems relying on preoperative image data have a decreasing accuracy during the surgical procedure. Intraoperative image data represent the correct anatomic situation, so their use may compensate for the effects of brain shift.METHODSIn a series of 16 brain tumor patients, we used intraoperative magnetic resonance (MR) imaging to obtain 3-D data, which were then transferred to the microscope-based neuronavigation system. With the help of bone fiducial markers these images were registered intraoperatively, updating the neuronavigation system.RESULTSIn all patients the updating of the neuronavigation system with the intraoperative MR data was successful. It led to reliable neuronavigation with high accuracy; the mean registration error of the update procedure in all patients was 1.1 mm. The updating procedure added about 15 minutes to the operation time. In all patients the area suggestive of remaining tumor was reached and the additional tumor could be resected, resulting in a complete tumor removal in 14 patients. In the remaining patients extension of the tumor into eloquent brain areas prevented a complete excision.CONCLUSIONSThe update of a neuronavigation system with intraoperative MR images reliably compensates for the effects of brain shift. This method allows completion of tumor removal in some difficult brain tumors.

Correlation of intra-operative ultrasound with histopathologic findings after tumour resection in supratentorial gliomas. A method to improve gross total tumour resection.

The aim of this study was to evaluate whether intra-operative ultrasound (= IOUS) is a suitable tool to detect residual tumour tissue after gross total resection in supratentorial gliomas. During a period of 18 months 45 patients with supratentorial gliomas (38 high-grade and 9 low-grade, according to the WHO-grading system [42]) were operated on. A series of 78 biopsies was taken from the resection cavity under continuous sonographic control at the end of surgery. Gross total tumour resection was intended in 34 patients (= 76%). The biopsy specimens were matched with the sonographic features at each biopsy site. The sonographic appearance of the resection margins were classified into 2 groups: (1) Irregular hyperechoic areas extending from the cavity into the iso-echogenic brain tissue and (2) a dense small (< or = 3 mm in diameter) rather regular hyperechoic rim surrounding the resection cavity. 47 out of 53 biopsies taken from hyperechoic areas (group I) (36 high-grade/11 low-grade) revealed solid tumour tissue (= 89%). 34 (= 72%) of these 47 areas were microscopically assessed as inconspicuous by the surgeon. 6 samples (4 high-grade/2 low-grade) contained tumour infiltration zone. 25 biopsies (23 high-grade/2 low-grade) taken from the hyperechoic rim [group 2] were diagnosed as follows: Normal brain tissue in 11, tumour infiltration zone in 8 and solid tumour tissue in 6 cases. Of 34 cases with "gross total removal" according to the surgeon's assessment 25 showed sonographic signs of residual tumour tissue, which was confirmed histologically as solid tumour tissue in 22 of these cases. It is concluded, that IOUS following resection of supratentorial gliomas can detect residual tumour tissue with high specificity and thus improve gross total resection. However, a thin hyperechoic rim surrounding the resection cavity (less than 3 mm in diameter) is a non-specific finding, which can mask thin residual tumour layers and therefore needs further evaluation of its nature.