5-ALA fluorescence in a WHO grade I papillary glioneuronal tumour: a case report

José Pedro Lavrador,Hussein Shaaban Kandeel,Alison Kalb,Ranjeev Bhangoo,Zita Reisz,Francesco Vergani,Keyoumars Ashkan,Richard Gullan,Safa Al-Sarraj

doi:10.1007/s00701-020-04223-x

José Pedro Lavrador, Hussein Shaaban Kandeel + Show 7 more

Open Access

https://doi.org/10.1007/s00701-020-04223-x

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Abstract

5-ALA is proven to be effective in high-grade glioma operative resection. The use of 5-ALA in WHO grade I lesions is still controversial. A 49-year-old lady was diagnosed in 2004 with a left temporal lobe lesion as an incidental finding; she was followed up clinically and radiologically. In 2016, the lesion showed contrast enhancement and she was offered surgical resection but given she is asymptomatic, she refused. In 2018, the lesion showed signs of transformation with ring contrast enhancement, increased vasogenic oedema and perfusion; the patient accepted surgery at that point. She had preoperative mapping by navigated transcranial magnetic stimulation and she had operative resection with 5-ALA. The tumour was bright fluorescent under Blue 400 filter—Zeiss Pentero 900©(Carl Zeiss Meditec)—and both bright fluorescence and pale fluorescence were resected. Postoperative MRI showed complete resection and histopathology revealed WHO grade I papillary glioneuronal tumour, negative for BRAF V600 mutation. WHO grade I papillary glioneuronal tumour may present as 5-ALA fluorescent lesions. From a clinical perspective, 5-ALA can be used to achieve complete resections in these lesions which, in most cases, can be curative.

Highlights

Background and importanceIn the last decades, clinical and imagiological follow-up of asymptomatic low-grade lesions was common practice
The authors present a rare case of a clinical and imagiological natural history of a papillary glioneuronal tumour (PGNT) that was treated with a presumptive diagnosis of a transforming low-grade glioma/high-grade glioma
The histopathological result revealed an unexpected WHO grade I papillary glioneuronal tumour, negative for BRAF V600 mutation (Fig. 5). Given these diagnoses and the complete resection achieved with the surgical resection, the multidisciplinary team decision was to follow-up this patient with no adjuvant treatment

Summary

Background and importance

Clinical and imagiological follow-up of asymptomatic low-grade lesions was common practice. The patient continued to be asymptomatic, but as the lesion showed signs of progression, surgical treatment was offered, but was declined Two years later, she remained asymptomatic, but imaging of the lesion revealed further signs of transforming lesion with ring contrast enhancement, increased vasogenic oedema and perfusion (Fig. 1m–u). She remained asymptomatic, but imaging of the lesion revealed further signs of transforming lesion with ring contrast enhancement, increased vasogenic oedema and perfusion (Fig. 1m–u) At this stage, the patient accepted the surgical treatment. The histopathological result revealed an unexpected WHO grade I papillary glioneuronal tumour, negative for BRAF V600 mutation (Fig. 5) Given these diagnoses and the complete resection achieved with the surgical resection, the multidisciplinary team decision was to follow-up this patient with no adjuvant treatment

Discussion

Compliance with ethical standards