5-Aminolevulinic acid fluorescence in high grade glioma surgery: surgical outcome, intraoperative findings, and fluorescence patterns.

Pietro Ciccarino,Marta Rossetto,Giuseppe Rolma,Alessandro Della Puppa,Giuseppe Lombardi,Diego Cecchin

doi:10.1155/2014/232561

Abstract

Background. 5-Aminolevulinic acid (5-ALA) fluorescence is a validated technique for resection of high grade gliomas (HGG); the aim of this study was to evaluate the surgical outcome and the intraoperative findings in a consecutive series of patients. Methods. Clinical and surgical data from patients affected by HGG who underwent surgery guided by 5-ALA fluorescence at our Department between June 2011 and February 2014 were retrospectively evaluated. Surgical outcome was evaluated by assessing the resection rate as gross total resection (GTR) > 98% and GTR > 90%. We finally stratified data for recurrent surgery, tumor location, tumor size, and tumor grade (IV versus III grade sec. WHO). Results. 94 patients were finally enrolled. Overall GTR > 98% and GTR > 90% was achieved in 93% and 100% of patients. Extent of resection (GTR > 98%) was dependent on tumor location, tumor grade (P < 0.05), and tumor size (P < 0.05). In 43% of patients the boundaries of fluorescent tissue exceeded those of tumoral tissue detected by neuronavigation, more frequently in larger (57%) (P < 0.01) and recurrent (60%) tumors. Conclusions. 5-ALA fluorescence in HGG surgery enables a GTR in 100% of cases even if selection of patients remains a main bias. Recurrent surgery, and location, size, and tumor grade can predict both the surgical outcome and the intraoperative findings.

Highlights

High grade gliomas are extremely aggressive lesions and represent the most common primary malignant brain tumors with an annual incidence of 5.26/100.000/year
Tumor location was analyzed on contrast-enhanced T1 sequences and the proximity to eloquent structures was assessed with diffusion tensor and functional Magnetic Resonance Imaging (MRI) images
Our study focused on defining the extent of resection and intraoperative fluorescence patterns in patients affected by high grade gliomas (HGG) who underwent surgery guided by 5-Aminolevulinic acid (5-ALA) fluorescence and assisted by MRI neuronavigation and neurophysiological monitoring

Summary

Introduction

High grade gliomas are extremely aggressive lesions and represent the most common primary malignant brain tumors with an annual incidence of 5.26/100.000/year. Among factors affecting patients’ outcome, extent of surgical removal and functional preservation have been proved to have a great impact; continuous refinements of surgical approaches and techniques are investigated [1,2,3]. The extent of tumor resection (EOR) is proved to be an important prognostic factor in HGG. Several neurosurgeons tried to quantify the EOR through a threshold of resection correlated with a significant improvement in overall survival. One of the most comprehensive series set this threshold at 95–100% rate of resection [4] with a median survival of 13 months compared with 8.8 months in patients with a EOR < 98%. Sanai and colleagues clearly demonstrated that in selected newly diagnosed HGG patient OS begins to benefit from an EOR ≥ 78% and that this trend of improvement increases at highest levels of resection [5]

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