Letter to the Editor: Diffuse glioma detection

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To The Editor: We have read with interest the article by Cage et al.2 (Cage TA, Pekmezci M, Prados M, et al: Subependymal spread of recurrent glioblastoma detected with the intraoperative use of 5-aminolevulinic acid. Case report. J Neurosurg 118:1220–1223, June 2013). We agree with the assertions that “magnetic resonance imaging may not completely detect the presence of diffuse tumor, . . . [and the] intraoperative use of fluorescence-assisted visualization with 5-ALA may be helpful in highlighting and detecting infiltrative tumor.” We have recently published data supporting that role of

To The Editor: We have read with interest the article by Cage et al.2 (Cage TA, Pekmezci M, Prados M, et al: Subependymal spread of recurrent glioblastoma detected with the intraoperative use of 5-aminolevulinic acid. Case report. J Neurosurg 118:1220–1223, June 2013). We agree with the assertions that “magnetic resonance imaging may not completely detect the presence of diffuse tumor, . . . [and the] intraoperative use of fluorescence-assisted visualization with 5-ALA may be helpful in highlighting and detecting infiltrative tumor.” We have recently published data supporting that role of 5-aminolevulinic acid (5-ALA).1 However, their statement that 5-ALA “confirmed that there was subependymal and ependymal spread” is unsupported, as they do not provide separate biopsies of those infiltrated areas. Optic radiation spreading would provide an alternative explanation for the connection of the recurrent tumor to the original site and would also explain the clinical symptoms.

In a number of papers, intense fluorescence from 5-ALA has been shown to be highly predictive of tumor histology;3–6 however, faint fluorescence in the ependymal wall might be an exception. We reviewed 45 patients with tumors contacting the ventricular wall and found ependymal fluorescence in 28. Selective biopsies were performed when taking the sample was considered safe, and the results were negative in 3 of 8 cases.7 Furthermore, clinical evolution of the group of patients with ependymal fluorescence was similar to the group without it, suggesting that there was not true ependymal spreading.

Disclosure

The authors report no conflict of interest.

References

  • 1

    Aldave-Orzaiz GATejada-Solís SValverde EPSánchez MMHerruzo BBIdoate Gastearena MA: Prognostic value of residual fluorescent tissue in glioblastoma patients after gross total resection in 5-ALA guided surgery. Neurosurgery [epub ahead of print]2013

  • 2

    Cage TAPekmezci MPrados MBerger MS: Subependymal spread of recurrent glioblastoma detected with the intraoperative use of 5-aminolevulinic acid. Case report. J Neurosurg 118:122012232013

  • 3

    Idoate MADíez Valle REcheveste JTejada S: Pathological characterization of the glioblastoma border as shown during surgery using 5-aminolevulinic acid-induced fluorescence. Neuropathology 31:5755822011

  • 4

    Nabavi AThurm HZountsas BPietsch TLanfermann HPichlmeier U: Five-aminolevulinic acid for fluorescence-guided resection of recurrent malignant gliomas: a phase II study. Neurosurgery 65:107010772009

  • 5

    Roberts DWValdés PAHarris BTFontaine KMHartov AFan X: Coregistered fluorescence-enhanced tumor resection of malignant glioma: relationships between δ-aminolevulinic acid-induced protoporphyrin IX fluorescence, magnetic resonance imaging enhancement, and neuropathological parameters. Clinical article. J Neurosurg 114:5956032011

  • 6

    Stummer WNovotny AStepp HGoetz CBise KReulen HJ: Fluorescence-guided resection of glioblastoma multiforme by using 5-aminolevulinic acid-induced porphyrins: a prospective study in 52 consecutive patients. J Neurosurg 93:100310132000

  • 7

    Tejada-Solis SAldave-Orzaiz GPay-Valverde EMarigil-Sanchez MIdoate-Gastearena MADiez-Valle R: Prognostic value of ventricular wall fluorescence during 5-aminolevulinic-guided surgery for glioblastoma. Acta Neurochir (Wien) 154:199720022012

Response

No response was received from the authors of the original article.

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Article Information

Please include this information when citing this paper: published online June 7, 2013; DOI: 10.3171/2013.3.JNS13498.

© AANS, except where prohibited by US copyright law.

Headings

References

1

Aldave-Orzaiz GATejada-Solís SValverde EPSánchez MMHerruzo BBIdoate Gastearena MA: Prognostic value of residual fluorescent tissue in glioblastoma patients after gross total resection in 5-ALA guided surgery. Neurosurgery [epub ahead of print]2013

2

Cage TAPekmezci MPrados MBerger MS: Subependymal spread of recurrent glioblastoma detected with the intraoperative use of 5-aminolevulinic acid. Case report. J Neurosurg 118:122012232013

3

Idoate MADíez Valle REcheveste JTejada S: Pathological characterization of the glioblastoma border as shown during surgery using 5-aminolevulinic acid-induced fluorescence. Neuropathology 31:5755822011

4

Nabavi AThurm HZountsas BPietsch TLanfermann HPichlmeier U: Five-aminolevulinic acid for fluorescence-guided resection of recurrent malignant gliomas: a phase II study. Neurosurgery 65:107010772009

5

Roberts DWValdés PAHarris BTFontaine KMHartov AFan X: Coregistered fluorescence-enhanced tumor resection of malignant glioma: relationships between δ-aminolevulinic acid-induced protoporphyrin IX fluorescence, magnetic resonance imaging enhancement, and neuropathological parameters. Clinical article. J Neurosurg 114:5956032011

6

Stummer WNovotny AStepp HGoetz CBise KReulen HJ: Fluorescence-guided resection of glioblastoma multiforme by using 5-aminolevulinic acid-induced porphyrins: a prospective study in 52 consecutive patients. J Neurosurg 93:100310132000

7

Tejada-Solis SAldave-Orzaiz GPay-Valverde EMarigil-Sanchez MIdoate-Gastearena MADiez-Valle R: Prognostic value of ventricular wall fluorescence during 5-aminolevulinic-guided surgery for glioblastoma. Acta Neurochir (Wien) 154:199720022012

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