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.

© AANS, except where prohibited by US copyright law.



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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.



Al-Mefty OKadri PASPravdenkova SSawyer JRStangeby CHusain M: Malignant progression in meningioma: documentation of a series and analysis of cytogenetic findings. J Neurosurg 101:2102182004


Borovich BDoron Y: Recurrence of intracranial meningiomas: the role played by regional multicentricity. J Neurosurg 64:58631986


de Vries JWakhloo AK: Repeated multifocal recurrence of grade I, grade II, and grade III meningiomas: regional multicentricity (primary new growth) or metastases?. Surg Neurol 41:2993051994


Ennis SRNovotny AXiang JShakui PMasada TStummer W: Transport of 5-aminolevulinic acid between blood and brain. Brain Res 959:2262342003


Iinuma SFarshi SSOrtel BHasan T: A mechanistic study of cellular photodestruction with 5-aminolevulinic acid-induced porphyrin. Br J Cancer 70:21281994


Jääskelainen J: Seemingly complete removal of histologically benign intracranial meningioma: late recurrence rate and factors predicting recurrence in 657 patients. A multivariate analysis. Surg Neurol 26:4614691986


Jääskelainen JHaltia MServo A: Atypical and anaplastic meningiomas: radiology, surgery, radiotherapy, and outcome. Surg Neurol 25:2332421986


Kallio MSankila RHakulinen TJääskelainen J: Factors affecting operative and excess long-term mortality in 935 patients with intracranial meningioma. Neurosurgery 31:2121992


Kawahara YNiiro MYokoyama SKuratsu J: Dural congestion accompanying meningioma invasion into vessels: the dural tail sign. Neuroradiology 43:4624652001


Kinjo TAl-Mefty OKanaan I: Grade zero removal of supratentorial convexity meningiomas. Neurosurgery 33:3943991993


Kuroiwa TKajimoto YOhta T: Development of a fluorescein operative microscope for use during malignant glioma surgery: a technical note and preliminary report. Surg Neurol 50:41491988


Lacroix MAbi-Said DFourney DRGokaslan ZLShi WDe-Monte F: A multivariate analysis of 416 patients with glioblastoma multiforme: prognosis, extent of resection, and survival. J Neurosurg 95:1901982001


Miyatake SKuwabara HKajimoto YKawabata SYokoyama KDoi A: Preferential recurrence of a sarcomatous component of a gliosarcoma after boron neutron capture therapy: case report. J Neurooncol 76:1431472006


Nakasu SNakasu YNakajima MMatsuda MHanda J: Pre-operative identification of meningiomas that are highly likely to recur. J Neurosurg 90:4554621999


Olivo MWilson BC: Mapping ALA-induced PPIX fluorescence in normal brain and brain tumor using confocal fluorescence microscopy. Int J Oncol 25:37452004


Peng QWarloe TBerg KMoan JKongshaug MGiercksky KE: 5-aminolevulinic acid-based photodynamic therapy. Clinical research and future challenges. Cancer 79:228223081997


Philippon JCornu PThe recurrence of meningiomas. Al-Mefty O: Meningiomas New YorkRaven Press1991. 87106


Pieper DRAl-Mefty OHanada YBuechner D: Hyperostosis associated with meningioma of the cranial base: secondary changes or tumor invasion. Neurosurg 44:7427471999


Salcman MMalignant meningiomas. Al-Mefty O: Meningiomas New YorkRaven Press1991. 7586


Shinoda JYano HYoshida SOkumura AKaku YIwama T: Fluorescence-guided resection of glioblastoma multiforme by using high-dose fluorescein sodium. Technical note. J Neurosurg 99:5976032003


Stafford SLPerry ASuman VJMeyer FBScheithauer BWLohse CM: Primarily resected meningiomas: outcome and prognostic factors in 581 Mayo Clinic patients, 1978 through 1988. Mayo Clin Proc 73:9369421998


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


Stummer WReulen HJNovotny AStepp HTonn JC: Fluorescence-guided resections of malignant gliomas—an overview. Acta Neurochir Suppl88:9122003


Stummer WStocker SWagner SStepp HFritsch CGoetz C: Intraoperative detection of malignant gliomas by 5-amino-levulinic acid-induced porphyrin fluorescence. Neurosurgery 42:5185261998




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