Original ArticleFluorescein-Guided Resection of Intramedullary Spinal Cord Tumors: Results from a Preliminary, Multicentric, Retrospective Study
Introduction
Intramedullary spinal cord tumors (IMSCTs) are relatively rare neoplasms comprising a miscellaneous group of tumors affecting the central nervous system (CNS). They represent 2%–4% of all CNS neoplastic lesions and are associated with a low incidence of approximately 1.1 cases per 100.000 persons.1, 2 Among them, ependymomas are the most common overall, and they frequently affect the adults, whereas astrocytomas present a much higher occurrence in the pediatric population.3 IMSCTs include heterogeneous lesions, and they consequently present a variable behavior ranging from highly aggressive to relatively indolent clinical course. Despite this finding, most IMSCTs appear with characteristic contrast enhancement on preoperative magnetic resonance imaging (MRI) because of a damaged blood-brain barrier (BBB).4, 5 Because surgical removal with possible gross total resection (GTR) represents the standard of care in the management of these tumors,6 the use of technical tools that can increase tumor visualization during surgical procedures could give a major contribution for patient prognosis.
For example, sodium fluorescein (SF) is a dye with the peculiar characteristic of accumulating in areas of the CNS showing damage to the BBB.7 Recently, dedicated filters with a specific wavelength for SF have been integrated into the surgical microscope.8 In this way, SF has been proposed as a fluorescent tracer for different kinds of tumors of the CNS, including high-grade gliomas, metastasis, lymphomas, and hemangioblastomas.9, 10, 11, 12 Given the pattern of contrast enhancement uptake on MRI of the majority of IMSCTs, the use of this fluorescent tracer could allow a better intraoperative discrimination of the different tumor subtypes compared with the surrounding normal spinal cord parenchyma. To our knowledge, we present the first experience with the application of a fluorescein-guided technique for surgical removal of IMSCTs.
Section snippets
Patients, Preoperative, and Postoperative Clinical and Neuroradiologic Evaluation
In this study, we retrospectively reviewed surgical databases, approved by a local ethical committee in 3 neurosurgical departments (Fondazione IRCCS Istituto Neurologico Besta, Milano, Italy; Department of Neurosurgery, Regensburg University Hospital, Regensburg, Germany; Department of Neurosurgery Liv Hospital Ulus affiliated with Istinye University Medical Faculty, Istanbul, Turkey), to identify the cohort of patients with IMSCTs who underwent surgical removal using the fluorescein-guided
Results
No patient received radiotherapy or chemotherapy before surgery or preoperative glucocorticoids.
Patients were in good preoperative neurologic and clinical condition, with an mRS score of 0 in 1 patient, 1 in 8 patients, and 3 in 2 patients.
Tumors were at the following locations in the spinal cord: 8 cervical, 1 cervicothoracic, 1 thoracic, 1 conus. Nine of 11 (82%) patients had contrast enhancement on preoperative MRI. In particular, 100% (5/5) of ependymomas, 100% (3/3) of hemangioblastomas,
Discussion
To our knowledge, our retrospective analysis showed for the first time that the use of SF could add significant advantages in terms of tumor visualization and resection for the vast majority of IMSCTs. In particular, bright fluorescence was present in all cases of ependymomas and pilocytic astrocytomas, whereas it was less evident for hemangioblastomas and absent in the grade II astrocytoma and benign glioneuronal tumor. These findings are clearly correlated to the characteristics enhancement
Conclusion
Our results suggest that fluorescein-guided surgery is a safe and effective technique that can be used during the surgical resection of IMSCTs with contrast enhancement on preoperative MRI. Prospective studies with long-term follow-up could provide major insights into the effects of fluorescein application on progression-free survival and overall survival of patients with IMSCTs.
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2022, World NeurosurgeryCitation Excerpt :SF is a synthetic organic compound accumulating in CNS areas with altered vessel permeability resulting from BBB alterations.44 Some investigators have shown that IMSCT contrast uptake on magnetic resonance imaging (T1 with contrast) matches SF intraoperative enhancing.19 Conversely, others have reported that SF staining is present not only in contrast-enhanced regions on preoperative magnetic resonance imaging but also in nonenhancing regions.45-47
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Conflict of interest statement: F. Acerbi, A. Brawanski, T. Kiris, and K-M. Schebesh received honoraria from the Zeiss Meditec Company for lectures at international congresses. This work was partially supported by a donation from Monico SpA (Venice, Italy).
Supplementary digital content available online.