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Modern Image-Guided Surgical Strategies in Neurosurgical Oncology

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A special issue of Brain Sciences (ISSN 2076-3425). This special issue belongs to the section "Neurotechnology and Neuroimaging".

Deadline for manuscript submissions: closed (30 September 2021) | Viewed by 10160

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Special Issue Editors

Dr. Thomas Picht

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Guest Editor

Department of Neurosurgery at the Charité Universitatsmedizin Berlin, Germany
Interests: brain tumors; navigated transcranial magnetici stimulation; DTI fiber tracking; preoperative planning; image-guided surgery

Dr. Giovanni Raffa

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Guest Editor

Division of Neurosurgery, BIOMORF Department, University of Messina, 98124 Messina, Italy
Interests: neuro-oncology; gliomas; preoperative planning; navigated transcranial magnetic stimulation (nTMS); DTI tractography
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Special Issue Information

Dear Colleagues,

The modern surgical treatment of brain tumors consists in the “maximal safe resection”, aiming at the maximal removal of neoplastic tissue while preserving surrounding neurovascular structures to reduce postoperative morbidity. In recent years, several neuroimaging techniques have been introduced in neurosurgical practice to plan and guide surgical resection, thus helping neurosurgeons to achieve the goal of the maximal safe resection. Different imaging techniques are currently used both in the preoperative period and during surgical resection, ranging from preoperative neuroimaging and neurophysiological technologies to plan the safest surgical strategy, up to intraoperative dyes and neuroimaging studies to improve the visualization of neoplastic tissue and verify the extent of tumor resection.

The scope of this Special Issue is to summarize the state of the art of modern preoperative, intraoperative, and postoperative neuroimaging techniques used in neuro-oncology to improve the surgical treatment and outcome of patients affected by brain tumors. The aim is to enhance knowledge of modern image-guided strategies in neurosurgical oncology, thus providing new insights into novel multidisciplinary image-guided approaches, ranging from strategies based on advanced preoperative functional imaging and planning, to modern approaches based on the intraoperative implementation of advanced neuroimaging-based technologies to improve the visualization of neoplastic tissue, the identification of eloquent neurovascular structures, and the assessment of the tumor extent of resection.

We are looking for studies focusing on the following imaging-based approach in neurosurgical oncology:

Multidisciplinary neuroimaging approaches combining advanced techniques, including nTMS/TMS, fMRI, MEG, and tractography, for preoperative planning and surgery of brain tumors;
Modern approaches to preoperative planning in neuro-oncology based on simulation, augmented reality, and virtual reality;
Intraoperative image-guided strategies to identify neoplastic tissue based on the use of fluorescent dyes (e.g., sodium fluoresceine, 5-ALA), on modern software-based analysis of the fluorescent signal, or on advanced histological analysis (e.g., intraoperative confocal microscopy);
Intraoperative neuroimaging technologies to assess the extent of tumor resection (e.g., iMRI, iCT, iUS);
Intraoperative multimodal image-guided strategies merging anatomofunctional information with advanced tools for the identification of neoplastic tissue that enable a safer and maximal tumor resection (e.g., navigation-based and microscope-based augmented reality);
Intraoperative imaging strategies to verify the integrity of vascular structures during and after tumor resection (e.g., indocianin-green videoangiography).

Original articles, review, minireview, editorials, commentary, technical notes, and case reports.

Dr. Thomas Picht
Dr. Giovanni Raffa
Guest Editors

Manuscript Submission Information

Manuscripts should be submitted online at www.mdpi.com by registering and logging in to this website. Once you are registered, click here to go to the submission form. Manuscripts can be submitted until the deadline. All submissions that pass pre-check are peer-reviewed. Accepted papers will be published continuously in the journal (as soon as accepted) and will be listed together on the special issue website. Research articles, review articles as well as short communications are invited. For planned papers, a title and short abstract (about 100 words) can be sent to the Editorial Office for announcement on this website.

Submitted manuscripts should not have been published previously, nor be under consideration for publication elsewhere (except conference proceedings papers). All manuscripts are thoroughly refereed through a single-blind peer-review process. A guide for authors and other relevant information for submission of manuscripts is available on the Instructions for Authors page. Brain Sciences is an international peer-reviewed open access monthly journal published by MDPI.

Please visit the Instructions for Authors page before submitting a manuscript. The Article Processing Charge (APC) for publication in this open access journal is 2200 CHF (Swiss Francs). Submitted papers should be well formatted and use good English. Authors may use MDPI's English editing service prior to publication or during author revisions.

Keywords

Brain tumors
Image-guided neurosurgery
Navigated transcranial magnetic stimulation
Tractography
Fluorescence-guided neurosurgery
Augmented reality
Virtual reality
Simulation in neurosurgery

Published Papers (5 papers)

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Research

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13 pages, 1418 KiB

Open AccessArticle

Predicting the Extent of Resection of Motor-Eloquent Gliomas Based on TMS-Guided Fiber Tracking

by Francesco Belotti, Mehmet Salih Tuncer, Tizian Rosenstock, Meltem Ivren, Peter Vajkoczy and Thomas Picht

Brain Sci. 2021, 11(11), 1517; https://doi.org/10.3390/brainsci11111517 - 16 Nov 2021

Cited by 5 | Viewed by 1540

Abstract

Background: Surgical planning with nTMS-based tractography is proven to increase safety during surgery. A preoperative risk stratification model has been published based on the M1 infiltration, RMT ratio, and tumor to corticospinal tract distance (TTD). The correlation of TTD with corticospinal tract to resection cavity distance (TRD) and outcome is needed to further evaluate the validity of the model. Aim of the study: To use the postop MRI-derived resection cavity to measure how closely the resection cavity approximated the preoperatively calculated corticospinal tract (CST) and how this correlates with the risk model and the outcome. Methods: We included 183 patients who underwent nTMS-based DTI and surgical resection for presumed motor-eloquent gliomas. TTD, TRD, and motor outcome were recorded and tested for correlations. The intraoperative monitoring documentation was available for a subgroup of 48 patients, whose responses were correlated to TTD and TRD. Results: As expected, TTD and TRD showed a good correlation (Spearman’s ρ = 0.67, p < 0.001). Both the TTD and the TRD correlated significantly with the motor outcome at three months (Kendall’s Tau-b 0.24 for TTD, 0.31 for TRD, p < 0.001). Interestingly, the TTD and TRD correlated only slightly with residual tumor volume, and only after correction for outliers related to termination of resection due to intraoperative monitoring events or the proximity of other eloquent structures (TTD ρ = 0.32, p < 0.001; TRD ρ = 0.19, p = 0.01). This reflects the fact that intraoperative monitoring (IOM) phenomena do not always correlate with preoperative structural analysis, and that additional factors influence the intraoperative decision to abort resection, such as the adjacency of other vulnerable structures. The TTD was also significantly correlated with variations in motor evoked potential (MEP) responses (no/reversible decrease vs. irreversible decrease; p = 0.03). Conclusions: The TTD approximates the TRD well, confirming the best predictive parameter and giving strength to the nTMS-based risk stratification model. Our analysis of TRD supports the use of the nTMS-based TTD measurement to estimate the resection preoperatively, also confirming the 8 mm cutoff. Nevertheless, the TRD proved to have a slightly stronger correlation with the outcome as the surgeon’s experience, anatomofunctional knowledge, and MEP observations influence the expected EOR. Full article

(This article belongs to the Special Issue Modern Image-Guided Surgical Strategies in Neurosurgical Oncology)

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12 pages, 1698 KiB

Open AccessArticle

The Relevant Role of Navigated Tractography in Speech Eloquent Area Glioma Surgery: Single Center Experience

by Luca Francesco Salvati, Raffaele De Marco, Giuseppe Palmieri, Massimiliano Minardi, Armando Massara, Alessandro Pesaresi, Bernarda Cagetti, Antonio Melcarne and Diego Garbossa

Brain Sci. 2021, 11(11), 1436; https://doi.org/10.3390/brainsci11111436 - 28 Oct 2021

Cited by 4 | Viewed by 1429

Abstract

Background: Gliomas are among the most challenging pathologies for neurosurgeons due to their infiltrative and recurrent nature in functionally relevant regions. Current knowledge confirms that gross total resection highly influence survival in patient with glioma. However, surgery performed in eloquent brain area, could seriously compromise the quality of life in patient with reduced life expectancy even more if it concerns the language function. Methods: 18 right-handed patients with perisylvian gliomas on the left hemisphere were prospectively analyzed over a period of 12 months. Standardized preoperative Diffusion-Tensor-Imaging based tractography of the five main language Tracts (Arcuate Fasciculus, Frontal Aslant Tract, Inferior Fronto-Occipital Fasciculus, Inferior Longitudinal Fasciculus, Uncinate Fasciculus) was navigated during the surgical procedure. Using a validated method, correlations were made between the pre-operative fascicles and their possible infiltration and surgical damage. The language status was assessed using the Aachen Aphasia Test. Results: In all nine patients who developed a permanent disorder there was pre-operative involvement of at least one fascicle and resection of at least one of these. In this way, areas of high risk of permanent language damage have emerged as a result of surgical injury: the temporoparietal junction, the middle portion of the FAT and the temporal stem. Conclusions: Navigated tractography has proven to be a user-friendly tool that can assess perioperative risk, guide surgical resection, and help the neurosurgeon to find that balance between tumor resection and function preservation. Full article

(This article belongs to the Special Issue Modern Image-Guided Surgical Strategies in Neurosurgical Oncology)

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9 pages, 855 KiB

Open AccessArticle

Let Me See: Correlation between 5-ALA Fluorescence and Molecular Pathways in Glioblastoma: A Single Center Experience

by Francesco Maria Calamo Specchia, Matteo Monticelli, Pietro Zeppa, Andrea Bianconi, Francesco Zenga, Roberto Altieri, Beatrice Pugliese, Giuseppe Di Perna, Fabio Cofano, Fulvio Tartara, Luca Bertero, Paola Cassoni, Antonio Melcarne, Michele Maria Lanotte and Diego Garbossa

Brain Sci. 2021, 11(6), 795; https://doi.org/10.3390/brainsci11060795 - 16 Jun 2021

Cited by 9 | Viewed by 2129

Abstract

Background: Despite the aggressiveness of multimodal treatment, glioblastoma (GBM) is still a challenge for neurosurgeons, neurooncologists, and radiotherapists. A surgical approach is still a cornerstone in GBM therapeutic management, as the extent of resection is strongly related both to overall survival and progression-free survival. From this perspective, the use of photodynamic molecules could represent an interesting tool to achieve maximal and safe resection. Being able to trace the lesion’s edges, indeed, could allow to improve the extent of resection and to minimize residual tumor while sparing normal tissue. The use of 5-aminolevulinic acid (5-ALA) as a photodynamic tracer is well established due to its strict correlation both with cellularity and metabolic activity of the GBM cell clones. Objective: Our study aims to define whether a different molecular asset of GBM (especially investigating IDH 1/2 mutation, proliferation index, and MGMT promoter methylation) results in different fluorescence expression, possibly because of differences in metabolic pathways due to different genotypes. Methods: Patients undergoing surgery for GBM removal at our Institute (Dep. Of Neurosurgery, Ospedale Città della Salute e della Scienza, University of Turin, Italy) were retrospectively reviewed. Patients with histological diagnosis confirmation and to whom 5-ALA was given before surgery were included. The whole surgical procedure was recorded and then analyzed by three different people (a medical student, a resident, and a senior surgeon with an interest in neurooncology and experience in using 5-ALA) and a score was assigned to the different degrees of intraoperative fluorescence. The degree of fluorescence was then matched with the genotype. Results: A trend of grade 2 fluorescence (i.e., ”strong”) was observed in the IDH 1/2 wild-type (WT) genotype, suggesting a more intense metabolic activity in this particular subgroup, while, no or weak fluorescence was observed more often in the IDH 1/2 mutated tumors, suggesting a lower metabolic activity. No relations were found between fluorescence grade and MGMT promoter methylation or, interestingly, cellularity. As a secondary analysis, more epileptogenicity of the IDH 1/2 mutated GBM was noticed, similarly to other recent literature. Conclusion: Our results do not support the use of 5-ALA as a diagnostic tool, or a way to substitute the molecular profiling, but confirm 5-ALA as a powerful metabolic tracer, able to easily detect the pathological cells, especially in the IDH WT genotype, and in this perspective, further studies will be necessary to better describe the metabolic activity of GBM cells. Full article

(This article belongs to the Special Issue Modern Image-Guided Surgical Strategies in Neurosurgical Oncology)

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10 pages, 2158 KiB

Open AccessArticle

⁶⁸Ga-DOTATOC PET/CT Follow Up after Single or Hypofractionated Gamma Knife ICON Radiosurgery for Meningioma Patients

by Fabio Barone, Francesco Inserra, Gianluca Scalia, Massimo Ippolito, Sebastiano Cosentino, Antonio Crea, Maria Gabriella Sabini, Lucia Valastro, Iolanda Valeria Patti, Stefania Mele, Grazia Acquaviva, Alessandra Tocco, Maria Tamburo, Francesca Graziano, Ottavio S. Tomasi, Rosario Maugeri, Gerardo Iacopino, Salvatore Cicero, Lidia Strigari and Giuseppe Emmanuele Umana

Brain Sci. 2021, 11(3), 375; https://doi.org/10.3390/brainsci11030375 - 15 Mar 2021

Cited by 25 | Viewed by 2311

Abstract

⁶⁸Ga-DOTATOC represents a useful tool in tumor contouring for radiosurgery planning. We present a case series of patients affected by meningiomas on who we performed ⁶⁸Ga-DOTATOC positron emission tomography (PET)/CT pre-operatively, a subgroup of which also underwent a post-operative ⁶⁸Ga-DOTATOC PET/CT to evaluate the standardized uptake value (SUV) modification after Gamma Knife ICON treatment in single or hypofractionated fractions. Twenty patients were enrolled/included in this study: ten females and ten males. The median age was 52 years (range 33–80). The median tumor diameter was 3.68 cm (range 0.12–22.26 cm), and the median pre-radiotherapy maximum SUV value was 11 (range 2.3–92). The average of the relative percentage changes between SUVs at baseline and follow up was −6%, ranging from −41% to 56%. The SUV was reduced in seven out of 12 patients (58%), stable in two out of 12 (17%), and increased in three out of 12 (25%), suggesting a biological response of the tumor to the Gamma Knife treatment in most of the cases. ⁶⁸Ga-DOTATOC-PET represents a valuable tool in assessing the meningioma diagnosis for primary radiosurgery; it is also promising for follow-up assessment. Full article

(This article belongs to the Special Issue Modern Image-Guided Surgical Strategies in Neurosurgical Oncology)

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Review

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10 pages, 1488 KiB

Open AccessReview

Fluorophores Use in Pituitary Surgery: A Pharmacokinetics and Pharmacodynamics Appraisal

by Daniele Bongetta, Fulvio Tartara, Fabio Pagella, Teresa Somma, Marilou Cavaliere, Giuseppe Di Perna, Francesco Zenga, Fabio Cofano, Diego Garbossa and Cesare Zoia

Brain Sci. 2021, 11(5), 565; https://doi.org/10.3390/brainsci11050565 - 28 Apr 2021

Cited by 6 | Viewed by 1889

Abstract

(1) Background: Despite many surgical and technological advances, pituitary adenoma surgery is still burdened by non-negligible rates of incomplete tumor resection, mainly due to difficulties in differentiating pathology from normal pituitary tissue. Some fluorescent agents have been recently investigated as intraoperative contrast agents in pituitary surgery. The aim of this study is to evaluate the actual knowledge about the usefulness of such fluorophores with a particular focus on both the pharmacokinetics and pharmacodynamics issues of the pituitary gland. (2) Methods: We reviewed the current literature about fluorophores use in pituitary surgery and reported the first fully endoscopic experience with fluorescein. (3) Results: The studies investigating 5-ALA use reported contrasting results. ICG showed encouraging results, although with some specificity issues in identifying pathological tissue. Low-dose fluorescein showed promising results in differentiating pathology from normal pituitary tissue. Apart from the dose and timing of administration, both the fluorophores’ volume of distribution and the histological variability of the interstitial space and vascular density played a crucial role in optimizing intraoperative contrast enhancement. (4) Conclusions: Both pharmacokinetics and pharmacodynamics issues determine the potential usefulness of fluorophores in pituitary surgery. ICG and fluorescein showed the most promising results, although further studies are needed. Full article

(This article belongs to the Special Issue Modern Image-Guided Surgical Strategies in Neurosurgical Oncology)

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