Coregistered fluorescence-enhanced tumor resection of malignant glioma: relationships between δ-aminolevulinic acid–induced protoporphyrin IX fluorescence, magnetic resonance imaging enhancement, and neuropathological parameters

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The aim of this study was to investigate the relationships between intraoperative fluorescence, features on MR imaging, and neuropathological parameters in 11 cases of newly diagnosed glioblastoma multiforme (GBM) treated using protoporphyrin IX (PpIX) fluorescence-guided resection.


In 11 patients with a newly diagnosed GBM, δ-aminolevulinic acid (ALA) was administered to enhance endogenous synthesis of the fluorophore PpIX. The patients then underwent fluorescence-guided resection, coregistered with conventional neuronavigational image guidance. Biopsy specimens were collected at different times during surgery and assigned a fluorescence level of 0–3 (0, no fluorescence; 1, low fluorescence; 2, moderate fluorescence; or 3, high fluorescence). Contrast enhancement on MR imaging was quantified using two image metrics: 1) Gd-enhanced signal intensity (GdE) on T1-weighted subtraction MR image volumes, and 2) normalized contrast ratios (nCRs) in T1-weighted, postGd-injection MR image volumes for each biopsy specimen, using the biopsy-specific image-space coordinate transformation provided by the navigation system. Subsequently, each GdE and nCR value was grouped into one of two fluorescence categories, defined by its corresponding biopsy specimen fluorescence assessment as negative fluorescence (fluorescence level 0) or positive fluorescence (fluorescence level 1, 2, or 3). A single neuropathologist analyzed the H & E–stained tissue slides of each biopsy specimen and measured three neuropathological parameters: 1) histopathological score (0–IV); 2) tumor burden score (0–III); and 3) necrotic burden score (0–III).


Mixed-model analyses with random effects for individuals show a highly statistically significant difference between fluorescing and nonfluorescing tissue in GdE (mean difference 8.33, p = 0.018) and nCRs (mean difference 5.15, p < 0.001). An analysis of association demonstrated a significant relationship between the levels of intraoperative fluorescence and histopathological score (χ2 = 58.8, p < 0.001), between fluorescence levels and tumor burden (χ2 = 42.7, p < 0.001), and between fluorescence levels and necrotic burden (χ2 = 30.9, p < 0.001). The corresponding Spearman rank correlation coefficients were 0.51 (p < 0.001) for fluorescence and histopathological score, and 0.49 (p < 0.001) for fluorescence and tumor burden, suggesting a strongly positive relationship for each of these variables.


These results demonstrate a significant relationship between contrast enhancement on preoperative MR imaging and observable intraoperative PpIX fluorescence. The finding that preoperative MR image signatures are predictive of intraoperative PpIX fluorescence is of practical importance for identifying candidates for the procedure. Furthermore, this study provides evidence that a strong relationship exists between tumor aggressiveness and the degree of tissue fluorescence that is observable intraoperatively, and that observable fluorescence has an excellent positive predictive value but a low negative predictive value.

Abbreviations used in this paper: ALA = δ-aminolevulinic acid; ALP = alkaline phosphatase; ALT = alanine aminotransferase; AST = aspartate aminotransferase; FGR = fluorescence-guided resection; GBM = glioblastoma multiforme; GdE = Gd-enhanced signal intensity; nCR = normalized contrast ratio; NPV = negative predictive value; PpIX = protoporphyrin IX; PPV = positive predictive value; ROI = region of interest.

Article Information

Address correspondence to: David W. Roberts, M.D., Section of Neurosurgery, Dartmouth-Hitchcock Medical Center, One Medical Center Drive, Lebanon, New Hampshire 03756. email:

Please include this information when citing this paper: published online April 9, 2010; DOI: 10.3171/.2010.2.JNS091322.

© AANS, except where prohibited by US copyright law.



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    Case 3. Images of a right parietal lesion. A: During resection, the surgical cavity displayed a high level of PpIX fluorescence (red) at the focal point of the surgical microscope (white cross hairs). B–D: Navigational information localized the focal point to an area of high contrast enhancement (red asterisks on MR images). E: Later during resection, the focal point of the operating microscope (white cross hairs) is focused on tissue with no observable PpIX fluorescence. F–H: Navigational information localized the focal point to an area without contrast enhancement (red asterisks).

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    Diagrams of the 95% CIs of the mean of MR image measures. Left: The 95% CIs of the mean for the GdE values from subtraction images of both fluorescent ([(+) F]; 57 samples, mean 15.38, 95% CI 11.07–19.69) and nonfluorescent ([(–) F]; mean 7.54, 95% CI 2.14–12.94) groups (random-effects, mixed model: mean difference 8.33, 95% CI 1.42–15.24; p = 0.018). Right: The 95% CIs of the mean for the nCR of both fluorescent (77 samples, mean 1.10, 95% CI –0.49 to 2.69) and nonfluorescent (mean –3.99, 95% CI –5.67 to –2.32) groups (random-effects, mixed model: mean difference 5.15, 95% CI 2.54–7.77; p < 0.001). The small black square in the middle of the vertical line represents the mean, and the whiskers represent the upper and lower 95% confidence limits of the mean.

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    Percentage bar graphs of fluorescence and neuropathological parameters. A relationship between qualitative fluorescence levels (0–3) and the two neuropathological parameters was observed. The Spearman rank correlation was 0.51 (p < 0.001) for the correlation between fluorescence and histopathological score (left), and 0.49 (p < 0.001) for the correlation between fluorescence and tumor burden (right).


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