Comparison of 5-aminolevulinic acid and sodium fluorescein for intraoperative tumor visualization in patients with high-grade gliomas: a single-center retrospective study

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OBJECTIVE

Maximal safe resection is an important surgical goal in the treatment for high-grade gliomas. Fluorescent dyes help the surgeon to distinguish malignant tissue from healthy. The aims of this study were 1) to compare the 2 fluorescent dyes 5-aminolevulinic acid (5-ALA) and sodium fluorescein (fluorescein) regarding extent of resection, progression-free survival, and overall survival; and 2) to assess the influence of other risk factors on clinical outcome and screen for potential disadvantages of the dyes.

METHODS

A total of 209 patients with high-grade gliomas were included in this retrospective study. Resections were performed in the period from 2012 to 2017 using 5-ALA or fluorescein. Extent of resection was assessed as the difference in tumor volume between early postoperative and preoperative MRI studies. Tumor progression–free survival and overall survival were analyzed using an adjusted Cox proportional hazards model.

RESULTS

One hundred fifty-eight patients were operated on with 5-ALA and 51 with fluorescein. The median duration of follow-up was 46.7 and 21.2 months, respectively. Covariables were evenly distributed. There was no statistically significant difference in volumetrically assessed median extent of resection (96.9% for 5-ALA vs 97.4% for fluorescein, p = 0.46) or the percentage of patients with residual tumor volume less than 0.175 cm3 (29.5% for 5-ALA vs 36.2% for fluorescein, p = 0.39). The median overall survival was 14.8 months for the 5-ALA group and 19.7 months for the fluorescein group (p = 0.06). The median adjusted progression-free survival was 8.7 months for the 5-ALA group and 9.2 months for the fluorescein group (p = 0.03).

CONCLUSIONS

Fluorescein can be used as a viable alternative to 5-ALA for intraoperative fluorescent guidance in brain tumor surgery. Comparative, prospective, and randomized studies are much needed.

ABBREVIATIONS 5-ALA = 5-aminolevulinic acid; ASA = American Society of Anesthesiologists; CRET = complete resection of contrast enhancing tumor; ECOG = Eastern Cooperative Oncology Group; EOR = extent of resection; GTR = gross-total resection; IDH-1 = isocitrate dehydrogenase 1; IQR = interquartile range; KPS = Karnofsky Performance Score; MGMT = O6-methylguanine-methyltransferase; OS = overall survival; PFS = progression-free survival; PR = partial resection; RANO = Response Assessment in Neuro-Oncology.
Article Information

Contributor Notes

Correspondence Rasmus W. Hansen: Odense University Hospital, Odense, Denmark. rasmus.wurgler.hansen@rsyd.dk.INCLUDE WHEN CITING Published online October 4, 2019; DOI: 10.3171/2019.6.JNS191531.Disclosures The authors report no conflict of interest concerning the materials or methods used in this study or the findings specified in this paper.
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