Near-Infrared Fluorescence with Second-Window Indocyanine Green as an Adjunct to Localize the Pituitary Stalk During Skull Base Surgery.
- 作者列表："Cho SS","Buch VP","Teng CW","De Ravin E","Lee JYK
:A potential application of near-infrared (NIR) fluorescence imaging using second-window indocyanine green (SWIG) is demonstrated. We hypothesized that because the pituitary lacks a blood-brain barrier, we might visualize the pituitary stalk using SWIG. A 52-year-old, right-handed man presented to our clinic for evaluation of progressive loss of vision. Physical examination was significant for loss of right peripheral vision and near-complete loss of left field vision. Prolactin was high-normal at 16.2 mg/dL. Brain magnetic resonance imaging demonstrated a 36-mm sellar mass extending superiorly and laterally crossing the intracranial left internal carotid artery, consistent with a nonfunctional pituitary macroadenoma. We elected to pursue left pterional craniotomy for resection. The patient was eligible for our SWIG clinical trial and consented to the study. SWIG is a novel, investigational technique using Food and Drug Administration-approved indocyanine green to enhance visualization of neoplastic tissue intraoperatively.1-7 The patient received 2.5 mg/kg of indocyanine green intravenously approximately 24 hours preoperatively. Intraoperatively, under white-light microscopy, the tumor was easily identified and distinguished from the optic nerves and internal carotid artery. After debulking of the gross tumor, NIR visualization using a laser-equipped endoscope8 demonstrated strong NIR fluorescence in the pituitary stalk. Despite the distorted anatomy, this technique enabled us to confidently identify and preserve the pituitary stalk. Postoperatively, the patient had persistently high urine output that normalized in 24 hours without desmopressin (sodium 139-140 mmol/L); after uneventful recovery, he was discharged with mild improvement in visual function. This case demonstrated a potential use of our SWIG protocol. As the stalk demonstrates strong NIR fluorescence after high-dose indocyanine green administration, surgeons may be able to better localize and preserve the stalk even in complex skull base tumor cases where the anatomy may be significantly distorted.
: 展示了使用第二窗口吲哚菁绿 (SWIG) 的近红外 (NIR) 荧光成像的潜在应用。我们假设，因为垂体缺乏血脑屏障，我们可以使用SWIG可视化垂体柄。一名 52 岁右利手男子到我们诊所接受进行性视力丧失的评估。体格检查对右周边视力丧失和左视野近完全丧失有重要意义。16.2 mg/dL时催乳素高-正常。脑磁共振成像显示 36mm鞍区肿块上侧穿过颅内左侧颈内动脉，符合无功能垂体大腺瘤。我们选择行左侧翼点开颅手术切除。患者有资格参加我们的SWIG临床试验，并同意这项研究。SWIG是一本小说，使用食品和药物管理局批准的吲哚菁绿增强术中肿瘤组织可视化的研究技术。1-7 患者术前约 24 小时接受 2.5 mg/kg吲哚菁绿静脉注射。术中，在白光显微镜下，肿瘤很容易与视神经和颈内动脉鉴别。在切除大体肿瘤后，使用配备激光的endoscope8 进行NIR可视化，在垂体柄中表现出很强的NIR荧光。尽管解剖结构扭曲，这项技术使我们能够自信地识别和保存垂体柄。术后患者持续高尿量，24 小时内恢复正常，无去氨加压素 (钠 139-140 mmol/L); 顺利恢复后，出院，视觉功能轻度改善。这个案例展示了我们的SWIG协议的潜在用途。由于高剂量吲哚菁绿给药后，茎表现出强烈的NIR荧光，即使在解剖结构可能明显扭曲的复杂颅base肿瘤病例中，外科医生也可能能够更好地定位和保存柄。
METHODS:OBJECTIVE:Large inoperable sacral chordomas show unsatisfactory local control rates even when treated with high dose proton therapy (PT). The aim of this study is assessing feasibility and reporting early results of patients treated with PT and concomitant hyperthermia (HT). METHODS: :Patients had histologically proven unresectable sacral chordomas and received 70 Gy (relative biological effectiveness) in 2.5 Gy fractions with concomitant weekly HT. Toxicity was assessed according to CTCAE_v4. A volumetric tumor response analysis was performed. RESULTS: :Five patients were treated with the combined approach. Median baseline tumor volume was 735 cc (range, 369-1142). All patients completed PT and received a median of 5 HT sessions (range, 2-6). Median follow-up was 18 months (range, 9-26). The volumetric analysis showed an objective response of all tumors (median shrinkage 46%; range, 9-72). All patients experienced acute Grade 2-3 local pain. One patient presented with a late Grade 3 iliac fracture. CONCLUSION:Combining PT and HT in large inoperable sacral chordomas is feasible and causes acceptable toxicity. Volumetric analysis shows promising early results, warranting confirmation in the framework of a prospective trial. ADVANCES IN KNOWLEDGE: :This is an encouraging first report of the feasibility and early results of concomitant HT and PT in treating inoperable sacral chordoma.
METHODS:BACKGROUND:National guidelines recommend screening and treatment for cancer-related bone disease and continued monitoring of bone-modifying agents. It is unclear whether a standardized screening tool is utilized to identify eligible patients and ensure appropriate supportive care is implemented. The purpose of this study was to evaluate current prescribing practices and optimize management of bone-modifying agents. METHODS:A retrospective chart review was performed to identify patients who received hormone deprivation therapy or had bone metastases through Hematology/Oncology or Urology clinics from 1 November 2016 to 31 October 2017. The primary endpoints of this study were the incidence of completed baseline dual-energy X-ray absorptiometry (DEXA) scan for patients on hormone deprivation therapy and percent of patients started on a bone-modifying agent for the prevention of skeletal-related events secondary to bone metastasis. Secondary endpoints included percent of patients with dental examinations prior to initiation, adequate calcium and vitamin D supplementation, incidence of osteonecrosis of the jaw or flu-like symptoms and education, and percent of bisphosphonate doses appropriately adjusted based on renal function. RESULTS:A total of 375 patients were assessed for baseline DEXA scans and bone-modifying therapy. Of the 226 patients on hormone deprivation therapy, 111 (49%) patients were appropriately screened with a DEXA scan prior to initiation of hormone deprivation therapy. Among the 149 patients with bone metastases, only 94 (63.1%) patients were started on a bone-modifying agent. CONCLUSIONS:Opportunities have been identified to optimize management of patients with cancer-related bone disease. Implementation of standardized tools may increase the rate of appropriate screening and initiation of bone-modifying therapy when warranted.
METHODS:PURPOSE:Low skeletal muscle mass has been associated with poor prognosis in patients with advanced lung cancer. However, little is known about the relationship between skeletal muscle mass and overall survival in patients with bone metastases from lung cancer. The objective of the present study was to evaluate the prognostic value of low trunk muscle mass in predicting overall survival in these patients. METHODS:The data from 198 patients who were diagnosed with bone metastases from lung cancer from April 2009 to May 2017 were retrospectively reviewed. The areas of the psoas and paravertebral muscles were measured at the level of the third lumbar vertebra on computed tomography scans taken at the time nearest to the diagnosis of bone metastasis. Muscle area was evaluated for male and female cohorts separately using different cutoff points. Cox proportional hazards analysis was performed to evaluate the factors independently associated with overall survival. RESULTS:The overall survival of patients in the lowest quartile for psoas muscle area or paravertebral muscle area was significantly shorter than that of patients above the 25th percentile for muscle area (p < 0.001). Multivariate analyses showed that paravertebral muscle mass (hazard ratio, 1.73; 95% confidence interval, 1.17-2.56; p = 0.006), epidermal growth factor receptor-targeted therapy, and performance status were independent prognostic factors. CONCLUSIONS:Low paravertebral muscle mass was associated with shorter survival, independently of known prognostic factors.