scholarly journals Intraoperative 5-ALA Fluorescence-Guided Resection of High-Grade Glioma Leads to Greater Extent of Resection with Better Outcomes: A Systematic Review

2021 ◽  
Author(s):  
Tiffany Eatz ◽  
Daniel Eichberg ◽  
Victor Lu ◽  
Long Di ◽  
Ricardo Jorge Komotar ◽  
...  
Keyword(s):  
Systematic Review ◽  
White Light ◽  
Randomized Clinical Trials ◽  
Aminolevulinic Acid ◽  
High Grade Glioma ◽  
Extent Of Resection ◽  
Fluorescent Imaging ◽  
Neurological Deficits ◽  
High Grade ◽  
Significant Difference

Abstract ImportanceHigh-grade gliomas (HGG) are the most aggressive and common malignant brain tumors in adults. They have a dismally fatal prognosis. Even if gross total resection of the enhancing tumor is achieved, inevitably, invading tumor cells that are indistinguishable to the un-aided eye are left behind, which eventually leads to tumor recurrence. 5-aminolevulinic acid (5-ALA) is an increasingly utilized intraoperative fluorescent imaging agent for patients with HGG. It enhances visualization of HGG tissue. Despite early promising randomized clinical trial data suggesting a survival benefit for 5-ALA-guided surgery, the growing body of literature must be analyzed to confirm efficacy on patient outcomes.Objective To perform a systematic review of the literature to evaluate whether there is a beneficial effect upon survival and extent of resection due to the utilization of 5-ALA in HGG surgery. Evidence ReviewLiterature regarding 5-ALA usage in HGG surgery was reviewed according to the PRISMA guidelines. One database, PubMed, was searched for assorted combinations of the keywords “5-ALA,” “high-grade glioma,” “5-aminolevulinic acid,” and “resection” in July 2020 for case reports and retrospective, prospective, and randomized clinical trials assessing and analyzing 5-ALA intraoperative use in patients with HGG. Entailed studies on PubMed and SCOPUS were found for screening using a snowball search technique upon the initially searched PubMed papers. Systematic reviews and meta-analyses were excluded from our PRISMA table. Findings1,951 previously published studies were screened, 536 of which were further evaluated, and ultimately 45 were included in our systematic review. There were no date restrictions on the screened publications. Our literature search was finalized on July 16, 2020. We found an observed increase in the overall survival (OS) and progression-free survival (PFS) of the 5-ALA group compared to the white light group, as well as an observed increase in the OS and PFS of complete resections compared to incomplete resections. Of the studies that directly compared the use of 5-ALA to white light (13 of the total analyzed 45, or 28.9%), 5-ALA lead to a better PFS and OS in 88.4% and 67.5% of patients, respectively. When the studies that reported postoperative neurologic outcomes of surgeries using 5-ALA vs. white light were analyzed, 42.2% of subjects demonstrated 5-ALA use was associated with less post-op neurological deficits, whereas 34.5% demonstrated no statistically significant difference between 5-ALA and without. 23.3% of studies showed that intraoperative 5-ALA guided surgeries lead to more post-op neurological deficits. Conclusions and RelevanceUtilization of 5-ALA was found to be associated with a greater extent of resection in HGG surgeries, as well as longer OS and PFS. Postop neurologic deficit rates were mixed and inconclusive when comparing 5-ALA groups to white light groups. 5-ALA is a useful surgical adjunct for resection of HGG when patient safety is preserved.

scholarly journals SURG-32. THE USE OF 5-AMINOLEVULINIC ACID IN LOW-GRADE GLIOMA RESECTION: A SYSTEMATIC REVIEW

2019 ◽  
Vol 21 (Supplement_6) ◽  
pp. vi246-vi246
Author(s):  
Ahmad Almekkawi ◽  
Tarek El Ahmadieh ◽  
Karl Abi-Aad ◽  
Salah Aoun ◽  
Najib EL Tecle ◽  
...  
Keyword(s):  
Systematic Review ◽  
Quality Index ◽  
Aminolevulinic Acid ◽  
High Grade Glioma ◽  
Extent Of Resection ◽  
Low Grade Glioma ◽  
Low Grade ◽  
High Grade ◽  
Visualization Technology ◽  
Glioma Resection

Abstract BACKGROUND 5-aminolevulinic acid is a reliable tool for optimizing high-grade glioma resection. However, its efficacy in low-grade glioma resection remains unclear. OBJECTIVE To study the role of 5-aminolevulinic acid in low-grade glioma resection and assess positive fluorescence rates and effect on the extent of resection. METHODS A systematic review of PubMed, Google Scholar, and Cochrane was performed from the date of inception to February 1, 2019. Studies that correlated 5-aminolevulinic acid fluorescence with low-grade glioma in the setting of operative resection were selected. Studies with biopsy only were excluded. Positive fluorescence rates were calculated. Quality index of the selected papers using the Downs and Black criteria checklist was provided. RESULTS Twelve articles met the selection criteria with 244 histologically-confirmed low-grade glioma patients who underwent microsurgical resection. All patients received 20 mg/kg body weight of 5-aminolevulinic acid. Only 60 patients (n=60/244; 24.5%) demonstrated visual intra-operative 5-aminolevulinic acid fluorescence. The extent of resection was reported in 4 studies, however, the data combined low- and high-grade tumors. Only 2 studies reported on tumor location. Only 3 studies reported on clinical outcomes. The Zeiss OPMI Pentero microscope was most commonly used across all studies. The average quality index was 14.58 (range: 10–17) which correlated with an overall good quality. CONCLUSION There is an overall low correlation between 5-aminolevulinic acid fluorescence and low-grade glioma. Advances in visualization technology and using standardized fluorescence quantification methods may further improve the visualization and reliability of 5-aminolevulinic acid fluorescence in low-grade glioma resection.

scholarly journals The role of 5-aminolevulinic acid in enhancing surgery for high-grade glioma, its current boundaries, and future perspectives: A systematic review

Cancer ◽  
2016 ◽  
Vol 122 (16) ◽  
pp. 2469-2478 ◽  
Author(s):  
Alireza Mansouri ◽  
Sheila Mansouri ◽  
Laureen D. Hachem ◽  
George Klironomos ◽  
Michael A. Vogelbaum ◽  
...  
Keyword(s):  
Systematic Review ◽  
Aminolevulinic Acid ◽  
High Grade Glioma ◽  
High Grade ◽  
Future Perspectives

scholarly journals SURG-18. 5-AMINOLEVULINIC ACID FLUORESCENCE (5-ALA) GUIDED RESECTION OF GLIOBLASTOMA, LESSON LEARNED FROM 19 CASES

2019 ◽  
Vol 21 (Supplement_6) ◽  
pp. vi243-vi243
Author(s):  
Jinmo Cho
Keyword(s):  
Aminolevulinic Acid ◽  
Tumor Resection ◽  
High Grade Glioma ◽  
Extent Of Resection ◽  
High Grade ◽  
Total Resection ◽  
Glioma Surgery ◽  
Term Survival ◽  
Tumor Bed ◽  
Key Factor

Abstract BACKGROUND 5-ALA is known as useful tool for high grade glioma resection and the accumulation extent of 5-ALA is known as far beyond gadolinium enhancement. Extent of resection is key factor for favorable outcome and long-term survival for high grade glioma patients and 5-ALA might increase extent of resection. We present our experience of 5-ALA guided glioma surgeries METHODS Total 19 patients were performed 5-ALA guided surgery. They ingested 20mg/kg, four hours before craniotomy. We tried to perform supra-total resection rather than gross total resection according to the tumor consistency and if the tumor located relatively non-eloquent area, we tried to perform lobectomy rather than lesionectomy. After tumor resection, we inspect the tumor bed under 5-ALA fluorescence, and we confirmed the complete loss of fluorescence on the tumor resected bed. We check the MRI within 48 hour after operation and assess the extent of resection RESULTS Among the 19 patients, 15 patients were confirmed glioblastoma and 3 anaplastic astrocytoma and 1 anaplastic oligoastrocytoma. We confirmed all enhancing lesion was completely removed, however, 2 patients show residual non-enhancing lesion in post-operative MRI. Two patients suffered temporary hemiparesis and 2 patients show permanent visual field defect. CONCLUSION 5-ALA is useful tool for glioma surgery. Resection extent could be increased, however, non-enhancing lesion in the high grade gliomas, might be missed under 5-ALA guidance.

scholarly journals Impact of fluorescence-guided surgery on the improvement of clinical outcomes in glioblastoma patients

2014 ◽  
Vol 1 (3) ◽  
pp. 81-85 ◽  
Author(s):  
Sung Kwon Kim ◽  
Seung Hong Choi ◽  
Yong Hwy Kim ◽  
Chul-Kee Park
Keyword(s):  
Clinical Outcomes ◽  
White Light ◽  
Aminolevulinic Acid ◽  
Progression Free Survival ◽  
Extent Of Resection ◽  
Clinical Impact ◽  
Resection Rate ◽  
Guided Surgery ◽  
Fluorescence Guided Surgery ◽  
Significant Difference

Abstract Background To evaluate the clinical impact of fluorescence-guided surgery (FGS) in glioblastoma, we analyzed the clinical data of 80 consecutive patients operated on by a single surgeon with or without 5-aminolevulinic acid (5-ALA). Methods We compared 3-dimensional volumetric extent of resection and clinical outcomes between 40 consecutive patients undergoing resection using a white-light (WL) microscope and 40 subsequent consecutive patients undergoing resection using FGS with 5ALA. Results By introducing FGS, there was a significant difference in the mean volumetric extent of the resection rate of T1-enhancing lesions (84.7% in the white-light group and 97.0% in the 5-ALA group, P = .002). The complete resection rate was improved from 43% to 80%, and the proportion of resections that were <80% was reduced from 26% to 4% by FGS. The median progression-free survival was significantly better in the 5-ALA group (18.0 months vs. 6.0 months; P = .001). Although the immediate postoperative functional status was slightly worse in the 5-ALA group, this trend had reversed itself by 3 months postoperatively. Conclusions The present study adds practical evidence of the clinical impact of 5-ALA FGS on glioblastomas from the surgeon's standpoint.

scholarly journals The Use of 5-Aminolevulinic Acid in Low-Grade Glioma Resection: A Systematic Review

2019 ◽  
Vol 19 (1) ◽  
pp. 1-8
Author(s):  
Ahmad Kareem Almekkawi ◽  
Tarek Y El Ahmadieh ◽  
Eva M Wu ◽  
Abdullah M Abunimer ◽  
Karl R Abi-Aad ◽  
...  
Keyword(s):  
Systematic Review ◽  
Quality Index ◽  
Aminolevulinic Acid ◽  
Extent Of Resection ◽  
Low Grade Glioma ◽  
Low Grade ◽  
High Grade ◽  
Patient Consent ◽  
Visualization Technology ◽  
Glioma Resection

Abstract BACKGROUND For optimizing high-grade glioma resection, 5-aminolevulinic acid is a reliable tool. However, its efficacy in low-grade glioma resection remains unclear. OBJECTIVE To study the role of 5-aminolevulinic acid in low-grade glioma resection and assess positive fluorescence rates and the effect on the extent of resection. METHODS A systematic review of PubMed, Google Scholar, and Cochrane was performed from the date of inception to February 1, 2019. Studies that correlated 5-aminolevulinic acid fluorescence with low-grade glioma in the setting of operative resection were selected. Studies with biopsy only were excluded. Positive fluorescence rates were calculated. The quality index of the selected papers was provided. No patient information was used, so Institutional Review Board approval and patient consent were not required. RESULTS A total of 12 articles met the selection criteria with 244 histologically confirmed low-grade glioma patients who underwent microsurgical resection. All patients received 20 mg/kg body weight of 5-aminolevulinic acid. Only 60 patients (n = 60/244; 24.5%) demonstrated visual intraoperative 5-aminolevulinic acid fluorescence. The extent of resection was reported in 4 studies; however, the data combined low- and high-grade tumors. Only 2 studies reported on tumor location. Only 3 studies reported on clinical outcomes. The Zeiss OPMI Pentero microscope was most commonly used across all studies. The average quality index was 14.58 (range: 10-17), which correlated with an overall good quality. CONCLUSION There is an overall low correlation between 5-aminolevulinic acid fluorescence and low-grade glioma. Advances in visualization technology and using standardized fluorescence quantification methods may further improve the visualization and reliability of 5-aminolevulinic acid fluorescence in low-grade glioma resection.

The Cost-Effectiveness of 5-ALA in High-Grade Glioma Surgery: A Quality-Based Systematic Review

2020 ◽  
Vol 47 (6) ◽  
pp. 793-799 ◽  
Author(s):  
Nebras M. Warsi ◽  
Rahel Zewude ◽  
Brij Karmur ◽  
Neda Pirouzmand ◽  
Laureen Hachem ◽  
...  
Keyword(s):  
Cost Effectiveness ◽  
Health Economics ◽  
White Light ◽  
Aminolevulinic Acid ◽  
Cost Utility ◽  
High Grade ◽  
Glioma Surgery ◽  
Life Years ◽  
Significant Difference ◽  
The Cost

ABSTRACT:Background:High-grade gliomas (HGGs) are aggressive tumors that inevitably recur due to their diffusely infiltrative nature. Intraoperative adjuncts such as 5-aminolevulinic acid (5-ALA) have shown promise in increasing extent of resection. As the prospect of increased use of 5-ALA rises, a systematic overview of the health economics of this adjunct is critical.Methods:Medline, EMBASE, Centre for Reviews and Dissemination, EconPapers, and Cochrane databases were searched for keywords relating to glioma, cost-effectiveness, and 5-ALA. Primary studies reporting on the health economics or cost-effectiveness of 5-ALA compared to white light surgery in HGG were included. Quality was assessed using the British Medical Journal guidelines.Results:Three studies were identified. All were European and conducted from the perspective of national healthcare systems. Two studies demonstrated the cost-utility of 5-ALA compared to white light (C$12,817 and C$13,508/quality-adjusted life-years (QALYs)). One assessed the cost-utility per gross total resection (C$6,813). Both these values were below the national cost-effectiveness thresholds for each respective study. The third study demonstrated no significant difference in cost of 5-ALA in glioblastoma resection (C$14,732) compared to prior to its routine use (C$15,936). The quality of these studies ranged from moderate to average. None of these studies considered patient perspective or indirect costs in their analysis.Conclusions:Growing evidence exists examining the health economic benefit of 5-ALA as an intraoperative adjunct for HGG resection. Additional studies within the Canadian context using 5-ALA, specifically incorporating patient and societal perspectives into the cost-utility analyses, are necessary to solidify this line of evidence.

scholarly journals SURG-39. 5-AMINOLEVULINIC ACID FLUORESCENCE (5-ALA) GUIDED RESECTION OF GLIOBLASTOMA, LESSON LEARNED FROM 26 CASES

2020 ◽  
Vol 22 (Supplement_2) ◽  
pp. ii211-ii212
Author(s):  
Jinmo Cho
Keyword(s):  
Aminolevulinic Acid ◽  
Tumor Resection ◽  
High Grade Glioma ◽  
Extent Of Resection ◽  
High Grade ◽  
Total Resection ◽  
Glioma Surgery ◽  
Term Survival ◽  
Tumor Bed ◽  
Key Factor

Abstract INTRODUCTION 5-ALA is known as useful tool for high grade glioma resection and the accumulation extent of 5-ALA is known as far beyond gadolinium enhancement. Extent of resection is key factor for favorable outcome and long-term survival for high grade glioma patients and 5-ALA might increase extent of resection. We present our experience of 5-ALA guided glioma surgeries. MATERIALS AND METHODS Total 26 patients were performed 5-ALA guided surgery. They ingested 20mg/kg, four hours before craniotomy. We tried to perform supra-total resection rather than gross total resection according to the tumor consistency and if the tumor located relatively non-eloquent area, we tried to perform lobectomy rather than lesionectomy. After tumor resection, we inspect the tumor bed under 5-ALA fluorescence, and we confirmed the complete loss of fluorescence on the tumor resected bed. We check the MRI within 48 hour after operation and assess the extent of resection. RESULTS Among the 26 patients, 22 patients were confirmed glioblastoma and 3 anaplastic astrocytoma and 1 anaplastic oligoastrocytoma. We confirmed all enhancing lesion was completely removed, however, 4 patients show residual non-enhancing lesion in post-operative MRI. Two patients suffered temporary hemiparesis and 2 patients show permanent visual field defect. CONCLUSION 5-ALA is useful tool for glioma surgery. Resection extent could be increased, however, non-enhancing lesion in the high grade gliomas, might be missed under 5-ALA guidance.

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