Abstract
Abstract INTRODUCTION 5-aminolevulinic acid (5-ALA) guided surgery has been reported to prolong progression-free survival of patients with high grade glioma. Although blue-light capable microscope enables us to detect fluorescence intraoperatively, visualization of anatomy is difficult under blue-light microscope. On the other hand, exoscope permits to visualize both fluorescence and anatomy under blue-light conditions. We introduce our glioma surgery using an exoscope equipped with a 5-ALA fluorescence visual system. METHODS We attempted maximal safe resection for the patients with high grade glioma using 3D/4K exoscope with 5-ALA-induced fluorescence, neuronavigation, and electrophysiological monitoring or awake mapping. Visualization of fluorescence and anatomy under blue light, extent of resection, morbidity, and postoperative infarction were retrospectively reviewed. RESULTS Twenty patients (age 26–79, male 10/female 10, glioblastoma 11/lower grade glioma 9) underwent exoscopic tumor removal. Intraoperative fluorescence was observed in 100% of the tumor with gadolinium enhancement. Surrounding structures such as white matter, vessels and nerves were clearly visualized under blue light. Even perforators were visible and could be preserved. Supra-total resection and gross total resection of gadolinium-enhancing tumor was achieved in 6 (30%) and 10 (50%) patients, respectively. Surgical morbidity included hemianopsia in 1 patient and transient hemiparesis in 1 patient. Postoperative infarction was observed in 2 (10%) patients, which tended to be lower compared to 23 of 77 (29.9%) patients with glioblastoma who underwent tumor resection with fluorescence-equipped microscope(p=0.05). CONCLUSION Clear visualization of 5-ALA-indced tumor fluorescence and anatomical structures with use of high resolution exoscope help maximal safe tumor resection. Longer progression-free survival is expected as a result of greater extent of tumor resection.
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