500 Fluorescein-guided Resection of High Grade Gliomas: A Meta-analysis

Abstract

INTRODUCTION: High grade gliomas (HGGs) have a poor prognosis despite current standard of care of surgery, chemotherapy, and radiation therapy. Achieving gross total resection (GTR) has been found to prolong survival in these patients. Intraoperative fluorescent agents are often used to aid resection of HGGs. Currently, 5-ALA is the only FDA-approved fluorescent agent but can be inconvenient to use, requiring ingestion hours before surgery, dark room isolation for 1-2 days post-operatively, and high cost. Another fluorescent agent commonly used is fluorescein sodium which is FDA approved for ocular surgeries and has a better side effect profile and is less costly than 5-ALA. Many studies have been published documenting the use of fluorescein in HGG resection, reporting rates of GTR and with some studies comparing it to a non-fluorescent or 5-ALA arm. In this meta-analysis, we provide statistical evidence of the efficacy in using fluorescein for HGG resection. METHODS: Following the PRISMA framework, we assessed 119 articles from Pubmed, Medline (Ovid), and BIOSIS Citation Index and found 23 eligible studies for meta-analysis, assessing the rates of GTR with fluorescein-guided resection of HGGs. RESULTS: Of the 23 eligible studies, 22 reported GTR rates. A pooled cohort of 336 patients underwent fluorescein-guided HGG resection with a GTR rate of 81% (95% CI, 73-89%; p<.001). 11 case-controlled studies were analyzed, showing a 23.6% increase in GTR rate in the fluorescein group compared to non-fluorescein-guided surgeries. CONCLUSION: This meta-analysis shows significantly increased GTR rates in fluorescein-guided resection of HGGs when compared to resection without fluorescein. This is comparable to GTR rates found with 5-ALA (76.8%) in previous meta-analyses. Though our results are statistically significant, there was significant heterogeneity in the fluorescein studies analyzed, so we cannot definitively conclude an association between fluorescein-guidance and GTR.