Use of 5-aminolevulinic acid in fluorescence-guided resection of meningioma with high risk of recurrence

Case report

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✓It has been established that fluorescence-guided resection using 5-aminolevulinic acid (5-ALA) is useful in glioma surgery. The authors report on a 65-year-old woman who had a huge atypical left-hemisphere meningioma, which extended into the skull and to the superior sagittal sinus and demonstrated fluorescence in response to administration of 5-ALA. After the tumor was removed, the operative field was observed under the fluorescent mode of a fluorescence surgical microscopy system. Several minute areas of residual tumor tissue were visualized as strong fluorescence behind the vein and sinus, in a part of the hypertrophic dura, and along the edge of the skull. These remnants were completely removed. The authors concluded that fluorescence-guided resection using 5-ALA is useful in cases of atypical meningiomas with a high risk of recurrence.

Abbreviations used in this paper:PPIX = protoporphyrin IX; MR = magnetic resonance; 5-ALA = 5-aminolevulinic acid.

Article Information

Address reprint requests to: Yoshinaga Kajimoto, M.D., Ph.D., Department of Neurosurgery, Osaka Medical College, 2-7 Daigaku-machi, Takatsuki City, Osaka 569-8686, Japan. email: neu039@poh. osaka-med.ac.jp.

© AANS, except where prohibited by US copyright law.

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Figures

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    Gadolinium-enhanced T1-weighted MR images. A: Preoperative images showing the large tumor with a dural tail sign that reached the superior sagittal sinus. Skull invasion is evident. B: Postoperative images obtained 24 hours after surgery. No enhancing lesion related to the meningioma was observed.

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    Intraoperative photographs obtained in the white-light mode (A, B, C, D) and in the fluorescence mode (A′, B′, C′, D′). All images were obtained using a fluorescence surgical microscope. Each set of corresponding images (A and A′, B and B′, C and C′, D and D′) shows a single field of view. A and A′: The main tumor mass showed bright fluorescence. B and B′: The edge of the resected bone showed multiple areas of fluorescence. C and C′: A small area of residual tumor was identified by fluorescence behind the cortical vein. D and D′: Hypertrophic dura mater (arrowheads) adjacent to the superior sagittal sinus demonstrated fluorescence activity due to tumor invasion.

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    Photomicrographs demonstrating histological findings. A: Main tumor mass. B: Tumor invasion (asterisk) into the skull. C: Hypertrophic dura mater showing 5-ALA–induced fluorescence. Asterisk indicates fluorescence-positive tumor invasion into dura mater; double asterisk indicates intradural tumor mass. D: Hypertrophic dura without 5-ALA–induced fluorescence. Asterisk indicates venous congestion. No tumor invasion was observed. H & E. Original magnifications × 100 (A) and × 20 (B, C, and D).

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    Schematic drawing showing areas most likely to harbor tumor remnants. A: Intradural invasion. B: Bone invasion. C: Dural extension. D: Tumor tissue behind vessels in the sulcus. The gray zone shows the extent of the tumor.

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