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New Probe Provides Vital Assist in Brain Cancer Surgery

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The bright pink regions in this brain photograph are cancerous tissue found and illuminated by the new probe. (Credit: Image courtesy of Dartmouth-Hitchcock Medical Center) ScienceDaily (July 24, 2012) Performing surgery to remove a brain tumor requires surgeons to walk a very fine line. If they leave tumor tissue behind, the tumor is likely to regrow; if they cut out too much normal tissue, they could cause permanent brain damage. "Primary brain tumors look just like brain tissue," says Keith Paulsen, PhD, a professor of biomedical engineering at Thayer School of Engineering and a member of the Cancer Imaging and Radiobiology Research Program at Norris Cotton Cancer Center. "But if you look at them under a particular kind of light, they look much different." To improve their ability to differentiate between tumor cells and healthy tissue, surgeons can have patients take an oral dose of the chemical 5aminolevulinic acid (ALA). An enzyme metabolizes ALA, producing the

fluorescent protein protoporphyrin IX (PpIX). Tumor cells have a higher metabolic rate than normal cells, so they accumulate more PpIX -- and therefore fluoresce, or "glow," when exposed to blue light. A cancer "flashlight" But this method was thought to be not sensitive enough to highlight brain tumors that are less metabolically active, like low-grade gliomas. To address this problem, MD-PhD student Pablo Valdes, PhD, and his research mentors -David Roberts, MD, the chief of neurosurgery at Dartmouth-Hitchcock Medical Center, and Dr. Paulsen -- used a probe (which they helped develop) that combines violet-blue and white light to simultaneously analyze both the concentration of PpIX and four other tumor biomarkers: PpIX breakdown products, oxygen saturation, hemoglobin concentration, and irregularity of cell shape and size. The probe reads how light travels when it hits the tissue, sends this data to a computer, runs it through an algorithm, and produces a straightforward answer as to whether the tissue is cancerous. "Our big discovery is that we can use the probe's reading of the fluorescing agent to measure the existence of a low-grade tumor in tissue," says Dr. Paulsen. "The probe is basically an enabling technology to show that information to the surgeon -- a visual aid." He says that when they first saw the results of using their fluorescing agent and probe on low-grade brain tumors, it was "jaw-dropping. The tumor glowed like lava." The Thayer/Norris Cotton Cancer Center/Dartmouth-Hitchcock Medical Center team, which has been working on the brain probe for about six years, built on research that was originally conducted in Germany about 15 years ago. But the German research did not focus on low-grade tumors. The assumption, Dr. Paulsen says, was that, due to the blood-brain barrier, low-grade tumors did not have enough PplX and therefore would not fluoresce. In a pilot study, Roberts operated on 10 patients with gliomas. He used a microscope throughout the surgery to see the fluorescence and used the handheld probe to evaluate sections of the tissue where the fluorescence was not definitive. After the surgeries were complete, a pathologist evaluated how accurately the probe had identified tumor tissue.

Striking results The results, published in the Journal of Biomedical Optics, are striking. Diagnoses based on only fluorescence had an accuracy of 64 percent. But when Roberts used the probe as well, the accuracy increased to 94 percent, meaning that Roberts was much more successful in differentiating between tumor tissue and normal tissue. Although the study was small, it introduces a promising method to help surgeons remove only what they want and nothing more. Dr. Paulsen says that a protocol is in place for a similar study on lung cancer tumors. He thinks the brain probe may have applications for other cancers as well, but for now the research will have to proceed one cancer type at a time. Portions of this article were written by Alannah Phelan and appeared in the Spring 2012 edition ofDartmouth Medicine. Share this story on Facebook, Twitter, and Google:

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APA MLA Dartmouth-Hitchcock Medical Center (2012, July 24). New probe provides vital assist in brain cancer surgery. ScienceDaily. Retrieved July 26, 2012, from http://www.sciencedaily.com/releases/2012/07/120724144536.htm Note: If no author is given, the source is cited instead. Disclaimer: This article is not intended to provide medical advice, diagnosis or treatment. Views expressed here do not necessarily reflect those of ScienceDaily or its staff.

Implication in Health and Practice: Surgeries of the brain are often critical operations performed on patients recording, brain imaging, and for neurological manipulations such as electrical stimulation and chemical titration. The brain may be the most important part of the body, excluding the heart. Undergoing this type of surgery may require a lot of effort in order to achieve the success of the surgery. Brain interventions must be planned so that the neurosurgeon can access and remove the tumor without causing unnecessary damage. Before the brain tumor can be removed, crucial questions must be answered. Solving these problems requires more than merely improving existing imaging methods. Mathematical analysis and models must be integrated to produce information about the location of the tumor, functional areas, and nerve fiber tracts, to increase the accuracy of patient-specific data, and to give the surgeon dependable knowledge. Furthermore, nerve tracts can be pushed or infiltrated by the brain tumor itself. If nerve tracts become damaged during an operation, there is a risk that distant functional areas connected to the tumor-afflicted part of the brain could be affected and induce lasting sensory, motor, and cognitive impairment. Therefore, neurosurgeons attempt to answer these questions for each patient during the planning stage of the brain operation to minimize the risks present in the intervention. To do so, surgeons require medical imagery of each patient's brain anatomy and function that is as realistic and precise as possible. With the use of the new probe, the cancerous tissue in the brain illuminates a different color compared from normal tissues that gives the surgeon the ability to differentiate between tumor cells and healthy tissue. The use of the new probe would revolutionize the trend in brain tumor removal that would result in the high success rate of cancerous mass removal in the brain and can lower the rate of recurrence as it is more successful in differentiating between cancerous tissue and normal tissue compared to the use of fluorescence which is less efficient in identifying the tissue.

Comments and Personal view: This article is about the use a new discovered probe and the importance of image guidance and to assess the relative contribution of the imaging modality to the safety and efficacy of brain tumor removal. Expect the neurosurgeon to review the risks and benefits of the surgery. From the patients point of view the idea of brain surgery can be frightening. Our personalities, intelligence, instincts, capabilities, memories, "who we are" is the area about to be assaulted. The mindset of How will it affect me? Based on expertise and experience doctors can only predict what you can realistically expect. With the discovery of the new probe, the use of it in every brain cancer surgery would entail a high rate of efficiency in maintaining the healthy tissue of the brain. In my opinion, adopting this new technology in brain surgery would be a giant step in the surgical area. But in my point of view, only few hospitals can adopt this new technology here in the Philippines unless provided the government would be funding the government tertiary hospitals in the country. Every health care provider wants every surgery to be successful. In order to do that, the new trends in this area should be adopted and be used in order to maintain efficiency. This new probe would be highly recommended in every brain tumor surgery to prevent complications like irreversible brain damage when too much healthy tissue is removed during the procedure. To the doctors who had used this probe, a further study and use would be recommended in order to ensure the consistency in the efficiency of the device. To nurses, the provision of health teachings to patients that will undergo the said procedure is very essential. The role of the nurse in the peri-operative setting is very important. Throughout all the phases of the perioperative period pre-operative, intraoperative, post-operative, the nurses greatly affect the patients psychologically, emotionally, and physiologically well being. The conditioning of the patient prior to surgery would be a huge part of the nurse. As for the nursing education, the new trends should be included in the provision of education as it is needed, in order not only for the students but also for the instructor itself being oriented and familiarized with this new technology and always ensuring the safety and efficiency of the outcome of the surgery

ANGELES UNIVERSITY FOUNDATION

Angeles City

COLLEGE OF NURSING
A.Y. 2012-2013

In Partial Fulfillment for the requirements in Nursing Care Management 106 RLE

JOURNAL READING:

New Probe Provides Vital Assist in Brain Cancer Surgery

Submitted by:

Gabriel Patrick J. Cabigting

Submitted to:

Jasleen S. Yumang, RN, MN BSN IV-6 Group 23

September 03, 2012