The role of 5-aminolevulinic acid in spinal tumor surgery: a review

Wainwright, John V.; Endo, Toshiki; Cooper, Jared; Tominaga, Teiji; Schmidt, Meic H.

doi:10.1007/s11060-018-03080-0

Cited by 17 publications

(13 citation statements)

References 50 publications

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“…Our result of a strong fluorescence rate of 44% is similar to the existing literature [2,[33][34][35]. Our results of the ependymoma grade II group having a strong fluorescence rate of 83% with the grade III group having a 100% strong fluorescence rate is in line with the rate and extent of fluores- cence in clinical studies of both infratentorial [35] and spinal ependymomas [36], approaching 90 and 100% positive strong fluorescence for ependymoma grade II and grade III respectively [35,37,38]. Contrast enhancement was almost uniform across the entire cohort of tumours, only 2 (10%) tumours (a classic MB arising in the left lateral cerebellar hemisphere, and a classic MB arising in the midline from the roof of the fourth ventricle) failed to enhance post gadolinium administration.…”

Section: Discussionsupporting

confidence: 91%

The Use of 5-Aminolevulinic Acid to Assist Gross Total Resection of Paediatric Posterior Fossa Tumours

Labuschagne

2020

Pediatr Neurosurg

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Background: 5-aminolevulinic acid (5-ALA) use is well established in the resection of adult high-grade gliomas. There is growing interest in its usefulness in the paediatric population. The potential benefit of 5-ALA-guided resection motivated our unit to offer the established adult protocol as off-label use. Objective: to determine if 5-ALA guided resection was routinely useful and offered increased gross total resection (GTR) results. Methods: Nineteen patients harbouring a posterior fossa tumour suggestive of either an ependymoma or medulloblastoma (MB) underwent surgery between January 2018 and October 2019. The mean age was 5 years (range 2–12 years). A dose of 20 mg/kg of 5-ALA (Gliolan®) was given 4 h preoperatively. Intraoperatively, the tumours were viewed under violet-blue light and the presence of fluorescence was recorded. Fluorescence status was compared with histopathological classification and grade, Ki-67 index, GTR rate, and a subjective determination of “usefulness” was determined. Results: The case series included ependymoma grade II (n = 6), ependymoma grade III (n = 4), and MB grade IV (n = 9). For the combined cohort, the strong fluorescence rate was 68% (n = 13), the heterogenous fluorescence rate was 26% (n = 5), and the completely negative fluorescence rate was 5% (n = 1). The strong fluorescence rate of 90% found in the combined ependymoma group compared to the 45% strong fluorescence rate in the MB group was statistically significant (p = 0.05). Within the MB group the Ki-67 index was found to be significantly higher in the strongly fluorescent group as opposed to the patchy or non-fluorescent group (77.5 vs. 40%, p = 0.016). Fluorescence was determined to be useful in 63% of all cases. There was no significant relationship between fluorescence and GTR. The relationship between perceived usefulness and resection was not statistically significant. No adverse drug reactions were recorded. Conclusion: This case series adds to the growing body of evidence demonstrating the safety of 5-ALA in the paediatric population. 5-ALA guided resection was found to be useful in the majority of cases but this did not correlate with GTR status. Ependymomas reliably fluoresce in 90% of cases, and 5-ALA-guided resection should be considered when a preoperative diagnosis of ependymoma is suspected.

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Section: Discussionsupporting

confidence: 91%

The Use of 5-Aminolevulinic Acid to Assist Gross Total Resection of Paediatric Posterior Fossa Tumours

Labuschagne

2020

Pediatr Neurosurg

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“…In two patients diagnosed with ependymoma WHO grade 2, the surgery was terminated by performing subtotal resection due to early motor-evoked potential signal loss, but GTR was provided in all other intramedullary ependymomas. Studies have reported that ependymomas are well stained with 5-ALA and Na-fluorescein, which is useful in determining the tumor cleavage plan by distinguishing the tumor from healthy spinal tissue cord ( 19 , 22 , 30 ). Acerbi et al presented their first experience of intramedullary tumor surgery under the YELLOW 560 filter with Na-fluorescein ( 19 ), wherein a total of 11 patients with various histopathologies were evaluated, all ependymomas (5/5) were homogeneously stained bright and subjected to gross total resection.…”

Section: Discussionmentioning

confidence: 99%

“…The GTR rate was reported lower, namely, as 69 and 80% in two other important series ( 39 , 40 ). The reason for not achieving GTR could be the absence of a tumor cleavage plan in ependymomas, loss of neurophysiological signal during surgery, and overlooking residual tumor tissue under white light ( 22 , 30 ). In this study, the staining pattern and GTR rate obtained in ependymomas are satisfactory considering the above, thus, we consider Na-fluorescein useful in the surgical treatment of ependymomas with a yellow filter.…”

Section: Discussionmentioning

confidence: 99%

“…In the literature, there are many studies examining spinal cord intradural tumors with 5-aminolevulinic acid (5-ALA) (30)(31)(32)(33), but few on Na-fluorescein. In a comprehensive 5-ALA study, 5-ALA was positive in spinal intramedullary gliomas and the vast majority of intradural meningiomas, and proven to be a useful technique, especially in intramedullary gliomas (33).…”

Section: Discussionmentioning

confidence: 99%

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Sodium Fluorescein for Spinal Intradural Tumors

et al. 2021

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Technological innovations in spinal intradural tumor surgery simplify treatment. Surgical treatment of cranial benign and malignant pathologies under microscope with sodium (Na)-fluorescein guidance has often been reported, but few studies have focused on spinal intradural tumors. We aimed to investigate the usefulness of Na-fluorescein under yellow filter in intradural spinal tumor surgery by retrospectively reviewing cases involving intramedullary and extramedullary tumors operated under the guidance of Na-fluorescein. Forty-nine adult patients with a diagnosis of spinal intradural tumor operated under a yellow filter (560 nm) microscope using Na-fluorescein dye were included in the study. Demographic data, such as age and sex, neurological status, extent of tumor resection, histopathological diagnosis, Na-fluorescein staining pattern, and its usefulness during surgery were noted and statistically analyzed. Of all recruited patients, 26 women (53.1%) and 23 men (46.9%), were included for analysis. The age range of the patients was 18–64 years, with a mean age of 41.6 ± 13.9. An intradural intramedullary mass was found in 30.6% (n = 15) of the patients, and an intradural extramedullary mass in 69.4% (n: 34). While Na-fluorescein staining was homogeneous in all intradural extramedullary tumors, 73.3% (n: 11) of intradural intramedullary tumors were homogeneous, and 13.3% (n: 2) moderately heterogeneous. In the whole study group, the Na-fluorescein staining pattern was helpful in surgical resection in 47 cases (95.9%). While 34/34 (100%) found it helpful for extramedullary tumors, 13/15 (86.7%) did in intramedullary tumors, and for 2/15 (13.3%) it was not. In conclusion, Na-fluorescein helps in distinguishing tumor from healthy tissue in intradural extramedullary and intramedullary tumor surgery under a yellow filter microscope in most cases, thus providing convenient assistance to surgeons.

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“…There was also 1 (33.3%) case in 3 of a 5-ALA positive subependymoma. Several articles [30][31][32] evaluated the utility of 5-ALA-guided removal of spinal lesions, finding positive fluorescence to be reliable especially in ependymomas and meningiomas.…”

Section: Discussionmentioning

confidence: 99%

Extending the Indications of 5-Aminolevulinic Acid for Fluorescence-Guided Surgery for Different Central Nervous System Tumors: A Series of 255 Cases in Latin America

Silva

Ramina

Neto

et al. 2022

Arquivos Brasileiros de Neurocirurgia: Brazilian Neurosurgery

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Introduction Fluorescence guidance with 5-aminolevulinic acid (5-ALA) is a safe and reliable tool in total gross resection of intracranial tumors, especially malignant gliomas and cases of metastasis. In the present retrospective study, we have analyzed 5-ALA-induced fluorescence findings in different central nervous system (CNS) lesions to expand the indications of its use in differential diagnoses. Objectives To describe the indications and results of 5-ALA fluorescence in a series of 255 cases. Methods In 255 consecutive cases, we recorded age, gender, intraoperative 5-ALA fluorescence tumor response, and 5-ALA postresection status, as well the complications related to the method. Postresection was classified as ‘5-ALA free’ or ‘5-ALA residual’. The diagnosis of histopathological tumor was established according to the current classification of the World Health Organization (WHO). Results There were 195 (76.4%) 5-ALA positive cases, 124 (63.5%) of whom underwent the ‘5-ALA free’ resection. The findings in the positive cases were: 135 gliomas of all grades; 19 meningiomas; 4 hemangioblastomas; 1 solitary fibrous tumor; 27 metastases; 2 diffuse large B cell lymphomas; 2 cases of radionecrosis; 1 inflammatory disease; 2 cases of gliosis; 1 cysticercosis; and 1 immunoglobulin G4-related disease. Conclusion Fluorescence with 5-ALA can be observed in lesions other than malignant gliomas or metastases, including meningiomas, hemangioblastomas, pilocytic astrocytomas, and lymphomas. Although there is need for further evidence for the use of 5-ALA beyond high-grade gliomas, it may be a safe and reliable tool to improve resection in positive tumors or to guide the histopathologic analysis in biopsies.

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The role of 5-aminolevulinic acid in spinal tumor surgery: a review

Cited by 17 publications

References 50 publications

The Use of 5-Aminolevulinic Acid to Assist Gross Total Resection of Paediatric Posterior Fossa Tumours

The Use of 5-Aminolevulinic Acid to Assist Gross Total Resection of Paediatric Posterior Fossa Tumours

Sodium Fluorescein for Spinal Intradural Tumors

Extending the Indications of 5-Aminolevulinic Acid for Fluorescence-Guided Surgery for Different Central Nervous System Tumors: A Series of 255 Cases in Latin America

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