Photosensitivity Reaction From Operating Room Lights After Oral Administration of 5-Aminolevulinic Acid for Fluorescence-Guided Resection of a Malignant Glioma

Abstract

Orally administered 5-aminolevulinic acid (5-ALA), which was approved in the United States in 2017, is preferentially metabolized by malignant glioma cells into protoporphyrin IX and enhances tumor visualization when using a blue light filter on an operating microscope. Photosensitivity after 5-ALA administration is a known side effect, but a photosensitivity reaction from operating room lights has not yet been documented. We report the case of a 56-year-old man with a history of previous resection of a grade II astrocytoma who presented with imaging concerning for tumor recurrence and possible malignant transformation. Repeat surgical resection utilized 5-ALA. Soon after the surgery, he developed reddening of his skin, particularly over the right side of his head and neck, with blistering and peeling in a distribution that was particularly exposed to operating room lights during surgery. No other areas of his skin experienced the same redness, blistering, or peeling. Topical lotions were applied and the skin changes resolved spontaneously over weeks. Significant photosensitivity after administration of oral 5-ALA is a rare complication, but neurosurgeons who perform fluorescence-guided tumor resection should remain cognizant of its potential association with exposure to intense light, including in the operating room. Phototoxicity typically is self-limited, but awareness is important to minimize its occurrence.

Novel combination of GammaTile cesium-131 brachytherapy with 5-aminolevulinic acid fluorescence–guided resection in the re-irradiation of pediatric recurrent high-grade glioma: illustrative case

“…1D ). The patient’s postoperative course was unremarkable, and he did not experience any adverse reaction to the 5-ALA. To manage post–5-ALA photosensitivity, 16 the patient remained in a darkened room for 48 hours after surgery without issue. Three weeks after surgery, he remained asymptomatic and had regained some of the facial symmetry lost prior to surgery.…”

Awake resection of recurrent astroblastoma with intraoperative 5-ALA–induced fluorescence: illustrative case

“…24 A notable aspect for surgeons desiring to use 5-ALA involves educating the care team and the patient that lights in the operating room and the patient's postoperative hospital room should be kept dim in the 24 hours postadministration because of the extremely rare but reported incidents of phototoxicity. 32 This challenge can be intensified by the on-and-off nature of the overhead lights in the operating room during awake craniotomies. Extra care must be taken to ensure that as much of the patient's exposed skin surfaces as possible are shaded while the patient can still maintain visualization of the speech pathologist or team member in charge of communication during the awake period of the surgery.…”