The impact of 5-aminolevulinic acid on extent of resection in newly diagnosed high grade gliomas: a systematic review and single institutional experience
Glioma surgery at its nascency relied predominantly on visual and tactile feedback for the removal of grossly abnormal tissue. This technique has inherent limitations in delineating infiltrative tumor from normal brain, thus limiting the ability to achieve a gross total resection consistently. Since extent of resection (EOR) is consistently correlated with measures of survival, fluorescence-guided surgery shows promise in improving our ability to treat high-grade gliomas (HGG). 5-Aminolevulinic acid (5-ALA) is a prodrug preferentially metabolized by glioma cells that allows direct, real-time visualization of pathologic tissue through fluorescence under blue light.
To report the relationship between 5-ALA and EOR in newly diagnosed HGG. To report our institutional experience including nuances of workflow.
The authors performed a systematic review of the available literature between 1998 and 2018 to isolate studies addressing the impact of fluorescence-guided surgery with 5-ALA on the EOR in newly diagnosed HGG. Search strategy was in adherence to the preferred reporting items for systematic reviews and meta-analyses methodology.
Out of 741 unique articles, eight fulfilled our strict inclusion criteria. Fluorescence-guided resection led to greater EOR in all studies, with six demonstrating statistical significance (p < 0.05). Two studies additionally demonstrated statistically significant increase in progression-free survival in the 5-ALA groups.
5-ALA has an unambiguously positive impact on improving EOR for newly diagnosed HGG. Since the nature of modern glioma surgery includes a complex arsenal of surgical adjuncts, 5-ALA is seldom examined in isolation and can be complemented by intraoperative MRI.
KeywordsAminolevulinic acid 5-Aminolevulinic acid Fluorescence-guided surgery High-grade glioma Extent of resection
Extent of resection
European Medicines Agency
Food and Drug Administration
Fluid attenuated inversion recovery
Gross total resection
Intraoperative magnetic resonance imaging
Karnofsky Performance Scale
Magnetic resonance sequence
Preferred reporting items for systematic reviews and meta-analyses
Compliance with ethical standards
Conflict of interest
Dr. Lee has consulting agreements with Medtronic and Monteris. Dr. Kalkanis has consulting agreements with Arbor Pharmaceuticals and Synaptive Medical. Dr. Haider and Dr. Lim declare that they have no conflict of interest.
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