STMO-9 Maximal safe glioma resection using high resolution exoscope

INTRODUCTION: Maximal safe glioma resection should be achieved using neuronavigation, electrophysiological monitoring, fluorescence visual system, and so on. Heads-up surgery with exoscope is suitable for the multimodal glioma surgery because multi-monitors come in our sights simultaneously. We introduce our glioma surgery using a latest exoscope and neuronavigation system. METHODS: We attempted maximal safe resection for the patients with high grade glioma using 3D/4K exoscope with 5-ALA-induced fluorescence, neuronavigation, and electrophysiological monitoring or awake mapping. An extent of resection, morbidity, and postoperative infarction were retrospectively reviewed. RESULTS: Twenty-one patients (age 26–79, male 11/female 10, glioblastoma 10/lower grade glioma 11, general anesthesia 16/awake craniotomy 5) underwent exoscopic tumor removal. Neuronavigation and electrophysiological monitoring were displayed in sub-monitors close to the main screen. Navigation could be recognized continuously using electromagnetic navigation technology. Intraoperative fluorescence was observed in 100% of the tumor with gadolinium enhancement. Surrounding structures such as white matter, vessels and nerves were clearly visualized under blue light. Supra-total resection or gross total resection was achieved in 8 (80%) of the patients with glioblastoma. Surgical morbidity included hemiparesis in 1 (4.8%) patient, hemianopsia in 1 (4.8%) patient. Postoperative infarction was observed in 2 (9.5%) patients, which was significantly lower compared to 23 of 77 (29.9%) patients with glioblastoma who underwent tumor resection with fluorescence-equipped microscope (p<0.05). CONCLUSION: High resolution exoscope surgery is effective for patients undergoing glioma surgery with respect to higher extent of resection and lower ischemic complication. Further studies are needed to assess direct comparisons between exoscope and microscope glioma resection.

Electromagnetic-Guided Interstitial Catheter Navigation for Gynecological Brachytherapy: a Phase I Trial (E-MINT)

<div>Catheter insertion for gynecological interstitial brachytherapy is a challenging surgical procedure due to the lack of real-time guidance available to Radiation Oncologists. To mitigate the limitations associated with catheter placement, electromagnetic navigation (EMN) was proposed as a solution to the current interstitial brachytherapy workflow. The sequence of events leading up to the completion of this project were as follows, the validation of the system and then the application of the EMN system in a clinical trial. Using a phantom-based validation method, submillimetric accuracy and jitter was characterized for the operational performance of an EMN system in a brachytherapy operating room environment.</div><div>Following validation, the EMN system was used for catheter placement in 5 patients, in an ongoing prospective clinical study. The mean catheter deflection documented was 3.52 +/- 2.53 mm when adopting EMN as a form of real-time guidance compared to 5.48 +/- 3.63 mm when the standard clinical workflow (SCW) was employed. The mean catheter spacing when using EMN was 9.31 +/- 4.81 mm compared to 7.09 +/- 6.06 mm when the SCW was followed. Also, the mean intraoperative time was 50.00 +/- 18.80 minutes for EMN and 38.20 +/- 15.29 minutes for the SCW.</div><div>The results of this project demonstrate that electromagnetic navigated interstitial catheter placement is promising as a real-time guidance option for the interstitial gynecological brachytherapy workflow. <br></div>

Electromagnetic-Guided Interstitial Catheter Navigation for Gynecological Brachytherapy: a Phase I Trial (E-MINT)

<div>Catheter insertion for gynecological interstitial brachytherapy is a challenging surgical procedure due to the lack of real-time guidance available to Radiation Oncologists. To mitigate the limitations associated with catheter placement, electromagnetic navigation (EMN) was proposed as a solution to the current interstitial brachytherapy workflow. The sequence of events leading up to the completion of this project were as follows, the validation of the system and then the application of the EMN system in a clinical trial. Using a phantom-based validation method, submillimetric accuracy and jitter was characterized for the operational performance of an EMN system in a brachytherapy operating room environment.</div><div>Following validation, the EMN system was used for catheter placement in 5 patients, in an ongoing prospective clinical study. The mean catheter deflection documented was 3.52 +/- 2.53 mm when adopting EMN as a form of real-time guidance compared to 5.48 +/- 3.63 mm when the standard clinical workflow (SCW) was employed. The mean catheter spacing when using EMN was 9.31 +/- 4.81 mm compared to 7.09 +/- 6.06 mm when the SCW was followed. Also, the mean intraoperative time was 50.00 +/- 18.80 minutes for EMN and 38.20 +/- 15.29 minutes for the SCW.</div><div>The results of this project demonstrate that electromagnetic navigated interstitial catheter placement is promising as a real-time guidance option for the interstitial gynecological brachytherapy workflow. <br></div>

Diffuse Idiopathic Neuroendocrine Cell Hyperplasia (DIPNECH) on Electromagnetic Navigation Bronchoscopy (EMN) Guided Fine Needle Aspiration (FNA): A Case Report

Introduction/Objective DIPNECH is a clinicopathological diagnosis characterized by abnormal proliferation of single or clusters of neuroendocrine cells in the bronchial mucosa. The World health organization includes DIPNECH as a preinvasive lesion to carcinoid tumors of the lung. Diagnosis is often delayed or missed due to insidious presentation and rarity of the disease. High degree of suspicion in the appropriate clinical and radiological context is important for early diagnosis. We describe a unique case of DIPNECH diagnosed by EMN guided aspiration cytology in the setting of multiple incidental lung nodules and confirmed on surgical resection. Methods/Case Report A 69-year-old female with history of insidious cough was referred to pulmonology clinic for multiple incidental bilateral lung nodules detected by CT scan, largest involving the right middle lobe. Although the main diagnostic consideration was pulmonary metastasis, several radiological features, including diffuse mosaic attenuation pattern, prompted the possibility of a diffuse neuroendocrine process. Electromagnetic navigation bronchoscopy (ENB) guided fine needle aspiration cytology was performed. Air-dried and Papanicolaou stained smears were scant but showed dispersed and clusters of small cells with fine chromatin with minimal cytoplasm. No necrosis or mitosis were seen. A cell block was prepared that showed rare clusters of tumor cells positive for immunostains synaptophysin, chromogranin, CD56, with a Ki-67 of 1%. In the appropriate clinical and radiological context findings were consistent with a well differentiated neuroendocrine process such as DIPNECH. Right middle lobe resection confirmed extensive DIPNECH with multiple typical carcinoid tumors and tumorlets. Results (if a Case Study enter NA) NA Conclusion It is essential to be familiar with the clinical and radiological findings of DIPNECH and include it in the differential diagnosis of its mimickers. Although the diagnosis is challenging on limited specimens, this report indicates that EMN guided aspiration cytology can be used as a valuable early tool for accurate diagnosis and timely management of DIPNECH.