Abstract
Simple SummaryComplete surgical removal of high-grade gliomas (HGG) is known to increase the overall survival and progression-free survival. Several studies have shown that fluorescence-guided surgery with 5-aminolevulinic acid (5-ALA) increases gross total resection considerably compared to white light surgery (65% vs. 36%). Recently, an off-label fluorophore, sodium fluorescein (SF), has become popular in fluorescence-guided surgery due to numerous utility benefits compared to 5-ALA, including lower cost, non-toxicity, easy administration during surgery and a wide indication for other CNS tumors. However, the level of evidence is inferior compared to 5-ALA. We reviewed the latest literature on fluorescence-guided surgery with 5-ALA and SF for brain tumors with emphasis on fluorescence-guided surgery in HGG and brain metastases. Further, we assessed the advantages and disadvantages of both fluorophores and discussed their future perspectives.Surgery is essential in the treatment of high-grade gliomas (HGG) and gross total resection (GTR) is known to increase the overall survival and progression-free survival. Several studies have shown that fluorescence-guided surgery with 5-aminolevulinic acid (5-ALA) increases GTR considerably compared to white light surgery (65% vs. 36%). In recent years, sodium fluorescein (SF) has become an increasingly popular agent for fluorescence-guided surgery due to numerous utility benefits compared to 5-ALA, including lower cost, non-toxicity, easy administration during surgery and a wide indication range covering all contrast-enhancing lesions with disruption of the blood–brain barrier in the CNS. However, currently, SF is an off-label agent and the level of evidence for use in HGG surgery is inferior compared to 5-ALA. Here, we give an update and review the latest literature on fluorescence-guided surgery with 5-ALA and SF for brain tumors with emphasis on fluorescence-guided surgery in HGG and brain metastases. Further, we assess the advantages and disadvantages of both fluorophores and discuss their future perspectives.
Highlights
High-grade gliomas (HGG) are the most common primary malignant brain cancer in adults [1,2]
A recent study by Glenn et al [11] showed that supramaximal resection (SMR), i.e., resection beyond the boundaries of contrast enhancement, further improved progression-free survival (PFS) and overall survival (OS) for the 32 glioma patients included in the study compared to gross total resection (GTR) and subtotal resection (STR), respectively, with PFS = 15 months vs. 7 months vs. 6 months (p < 0.003) and OS = 24 months vs. 11 months vs. 9 months (p < 0.004)
We focused on the use of 5-aminolevulinic acid (5-ALA) and sodium fluorescein (SF) for HGG surgery as this indication currently has the strongest level of evidence, we discussed the use of SF for other neurosurgical indications with emphasis on brain metastases
Summary
High-grade gliomas (HGG) are the most common primary malignant brain cancer in adults [1,2]. The authors found no statistically significant differences in the postoperative rate of complications between the groups [11] These findings support the notion that glioma surgery should aim for resection to the functional limit of the peritumoral region. It can be difficult to distinguish healthy brain tissue from tumor-infiltrated tissue when surgery is performed under white light, which is the most common technique in many centers (Figure 1A). These issues result in suboptimal EOR with historical GTR rates of approximately 36–52% [12,13] despite the use of supportive technologies such as neuronavigation systems and intraoperative MRI
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