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Combining 5-ALA fluorescence and intraoperative MRI in glioblastoma surgery: a histology-based evaluation


Hauser, Sonja B; Kockro, Ralf A; Actor, Bertrand; Sarnthein, Johannes; Bernays, René-Ludwig (2016). Combining 5-ALA fluorescence and intraoperative MRI in glioblastoma surgery: a histology-based evaluation. Neurosurgery, 78(4):475-483.

Abstract

BACKGROUND: Glioblastoma resection guided by 5-aminolevulinic acid (5-ALA) fluorescence and intraoperative magnetic resonance imaging (iMRI) may improve surgical results and prolong survival.
OBJECTIVE: To evaluate 5-ALA fluorescence combined with subsequent low-field iMRI for resection control in glioblastoma surgery.
METHODS: Fourteen patients with suspected glioblastoma suitable for complete resection of contrast-enhancing portions were enrolled. The surgery was carried out using 5-ALA-induced fluorescence and frameless navigation. Areas suspicious for tumor underwent biopsy. After complete resection of fluorescent tissue, low-field iMRI was performed. Areas suspicious for tumor remnant underwent biopsy under navigation guidance and were resected. The histological analysis was blinded.
RESULTS: In 13 of 14 cases, the diagnosis was glioblastoma multiforme. One lymphoma and 1 case without fluorescence were excluded. In 11 of 12 operations, residual contrast enhancement on iMRI was found after complete resection of 5-ALA fluorescent tissue. In 1 case, the iMRI enhancement was in an eloquent area and did not undergo a biopsy. The 28 biopsies of areas suspicious for tumor on iMRI in the remaining 10 cases showed tumor in 39.3%, infiltration zone in 25%, reactive central nervous system tissue in 32.1%, and normal brain in 3.6%.
CONCLUSION: 5-ALA fluorescence-guided resection may leave some glioblastoma tissue undetected. MRI might detect areas suspicious for tumor even after complete resection of all fluorescent tissue; however, due to the limited accuracy of iMRI in predicting tumor remnant (64.3%), resection of this tissue has to be considered with caution in eloquent regions.
ABBREVIATIONS: 5-ALA, 5-aminolevulinic acidCRET, complete resection of contrast-enhancing tumorEOR, extent of resectioniMRI, intraoperative magnetic resonance imaging.

Abstract

BACKGROUND: Glioblastoma resection guided by 5-aminolevulinic acid (5-ALA) fluorescence and intraoperative magnetic resonance imaging (iMRI) may improve surgical results and prolong survival.
OBJECTIVE: To evaluate 5-ALA fluorescence combined with subsequent low-field iMRI for resection control in glioblastoma surgery.
METHODS: Fourteen patients with suspected glioblastoma suitable for complete resection of contrast-enhancing portions were enrolled. The surgery was carried out using 5-ALA-induced fluorescence and frameless navigation. Areas suspicious for tumor underwent biopsy. After complete resection of fluorescent tissue, low-field iMRI was performed. Areas suspicious for tumor remnant underwent biopsy under navigation guidance and were resected. The histological analysis was blinded.
RESULTS: In 13 of 14 cases, the diagnosis was glioblastoma multiforme. One lymphoma and 1 case without fluorescence were excluded. In 11 of 12 operations, residual contrast enhancement on iMRI was found after complete resection of 5-ALA fluorescent tissue. In 1 case, the iMRI enhancement was in an eloquent area and did not undergo a biopsy. The 28 biopsies of areas suspicious for tumor on iMRI in the remaining 10 cases showed tumor in 39.3%, infiltration zone in 25%, reactive central nervous system tissue in 32.1%, and normal brain in 3.6%.
CONCLUSION: 5-ALA fluorescence-guided resection may leave some glioblastoma tissue undetected. MRI might detect areas suspicious for tumor even after complete resection of all fluorescent tissue; however, due to the limited accuracy of iMRI in predicting tumor remnant (64.3%), resection of this tissue has to be considered with caution in eloquent regions.
ABBREVIATIONS: 5-ALA, 5-aminolevulinic acidCRET, complete resection of contrast-enhancing tumorEOR, extent of resectioniMRI, intraoperative magnetic resonance imaging.

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Additional indexing

Item Type:Journal Article, refereed, original work
Communities & Collections:04 Faculty of Medicine > University Hospital Zurich > Clinic for Neurosurgery
Dewey Decimal Classification:610 Medicine & health
Language:English
Date:April 2016
Deposited On:15 Feb 2016 14:09
Last Modified:28 Mar 2017 10:28
Publisher:Lippincott Williams & Wilkins
ISSN:0148-396X
Publisher DOI:https://doi.org/10.1227/NEU.0000000000001035
PubMed ID:26407129

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