Comparison of 5-aminolevulinic acid and sodium fluorescein for intraoperative tumor visualization in patients with high-grade gliomas: a single-center retrospective study

Abstract

<jats:sec><jats:title>OBJECTIVE</jats:title><jats:p>Maximal safe resection is an important surgical goal in the treatment for high-grade gliomas. Fluorescent dyes help the surgeon to distinguish malignant tissue from healthy. The aims of this study were 1) to compare the 2 fluorescent dyes 5-aminolevulinic acid (5-ALA) and sodium fluorescein (fluorescein) regarding extent of resection, progression-free survival, and overall survival; and 2) to assess the influence of other risk factors on clinical outcome and screen for potential disadvantages of the dyes.</jats:p></jats:sec><jats:sec><jats:title>METHODS</jats:title><jats:p>A total of 209 patients with high-grade gliomas were included in this retrospective study. Resections were performed in the period from 2012 to 2017 using 5-ALA or fluorescein. Extent of resection was assessed as the difference in tumor volume between early postoperative and preoperative MRI studies. Tumor progression–free survival and overall survival were analyzed using an adjusted Cox proportional hazards model.</jats:p></jats:sec><jats:sec><jats:title>RESULTS</jats:title><jats:p>One hundred fifty-eight patients were operated on with 5-ALA and 51 with fluorescein. The median duration of follow-up was 46.7 and 21.2 months, respectively. Covariables were evenly distributed. There was no statistically significant difference in volumetrically assessed median extent of resection (96.9% for 5-ALA vs 97.4% for fluorescein, p = 0.46) or the percentage of patients with residual tumor volume less than 0.175 cm<jats:sup>3</jats:sup> (29.5% for 5-ALA vs 36.2% for fluorescein, p = 0.39). The median overall survival was 14.8 months for the 5-ALA group and 19.7 months for the fluorescein group (p = 0.06). The median adjusted progression-free survival was 8.7 months for the 5-ALA group and 9.2 months for the fluorescein group (p = 0.03).</jats:p></jats:sec><jats:sec><jats:title>CONCLUSIONS</jats:title><jats:p>Fluorescein can be used as a viable alternative to 5-ALA for intraoperative fluorescent guidance in brain tumor surgery. Comparative, prospective, and randomized studies are much needed.</jats:p></jats:sec>

5-ALA in Suspected Low-Grade Gliomas: Current Role, Limitations, and New Approaches

“…Aside from 5-ALA other fluorophores were additionally investigated for fluorescence guided resection in HGG as well as LGG. One alternative to 5-ALA for intraoperative fluorescence represents sodium fluorescein (134)(135)(136)(137). Sodium fluorescein is a technique for intraoperative fluorescence-guided resection in HGG, however, it showed no benefit in LGG surgery as no intraoperative yellow fluorescence was evident in LGG tissue (138,139).…”

Targeting the Axl and mTOR Pathway Synergizes Immunotherapy and Chemotherapy to Butylidenephthalide in a Recurrent GBM

“…Fluorescein sodium was used during surgery to improve the rate of gross total resection and visualize the tumor [ 38 , 40 ] ( Figure 2(a) ). Next, six pieces of CWs were placed into the suspected residual tumor cavity and fixed with bioabsorbable hemostatic meshes and fibrin sealant (Figures 2(b) – 2(f) ).…”

Congress of neurological surgeons systematic review and evidence-based guidelines update on the role of cytoreductive surgery in the management of progressive glioblastoma in adults

“…In patients undergoing reoperation of their recurrent GBM, Nabavi et al demonstrated that 5-ALA remains a useful tool in detecting recurrent gliomas, even after previous treatments with radiation, chemotherapy, or prior resections [13]. Recently, uorescein sodium has been shown to be a viable alternative to 5-ALA in uorescence-guided resection of malignant gliomas for both primary [14] and recurrent gliomas [15].…”