Abstract
5-Aminolevulinic acid (5-ALA) is a useful and well-established adjunct for glioblastoma surgery. A growing body of evidence has revealed the potential utility of 5-ALA in grade II and grade III glioma patients as well. However, reliable means of identifying in whom fluorescence will occur have not been established. The authors report the case of such an indeterminate-grade glioma highlighting two pearls of 5-ALA fluorescence in this subgroup of patients. Firstly, 5-ALA–guided tissue sampling helps to ensure that the true grade of the lesion is not underestimated. Secondly, intraoperative fluorescence can serve as a prognostic marker.The video can be found here: https://stream.cadmore.media/r10.3171/2021.10.FOCVID21196
Highlights
5-Aminolevulinic acid (5-ALA) is a useful and well-established adjunct for glioblastoma surgery
According to a recent systematic review, factors such as proliferative activity, cellular density, blood-brain barrier permeability, vascularity, and anaplasia may correlate with the intensity of low-grade glioma fluorescence.[1]
1:54 Generally, visible fluorescence is observed in 98%–100% of glioblastoma patients treated with 5-ALA.[2,3]
Summary
5-Aminolevulinic acid (5-ALA) is a useful and well-established adjunct for glioblastoma surgery. 1:54 Generally, visible fluorescence is observed in 98%–100% of glioblastoma patients treated with 5-ALA.[2,3] In contrast, visible fluorescence is observed in approximately 75%–85% of all grade III gliomas and 16%–20% of grade II diffuse gliomas.[2,4] In those cases, 5-ALA fluorescence is reported to correlate with signal intensity on FET-PET.[2,5,6] Here, fluorescence was coregistered with the available preoperative imaging data using neuronavigation. Separate biopsies were taken from both areas of FET-PET positivity including the fluorescing part of the tumor to best represent intratumoral heterogeneity. This helps not to underestimate the true grade of the lesion.[5] Especially due to shift in tissue masses during resection of large lesions, finding an anaplastic focus can be challenging.
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