Introduction: Malignant glioma represents a relevant therapeutic issue and the value of extensive surgical resection remains debated; recent evidence suggests that radical removal is associated with better survival. Several series report that the 5-amino-levulinic acid (5-ALA)fluorescence-guided resection increases the extension of tumor removal, by improving survival. Furthermore, in advanced age the radiotherapy and chemotherapy are often associated with increased toxicity related to the residual volume tumor.
Methods: The present experience is related to 35 patients affected by glioblastoma(30 newly diagnosed and 5 recurrent tumors). All patients underwent preoperative and early postoperative MRI, showing contrast enhancing lesions. All patients with KPS>70 were selected for fluorescence-guided resection. An oral dose of 20 mg 5-ALA /kg bw was administered to each patient. Microsurgical resection was performed by an operating microscope enabled to visualize the fluorescence. Only 14 patients, as first line treatment, have been submitted to radiotherapy and chemotherapy; second and in some cases third line treatments were utilized in recurrent cases. The patients follow-up ranged from 6 months to 3 years.
Results: In all patients tumor tissue showed intraoperative red fluorescence with different intensity; mainly in recurrent GBM, fluorescence-guided surgery allowed a better definition of active tumor, with net margins from perilesional “healthy” brain or radionecrosis. Postoperative KPS improved. Early postoperative MRI confirmed gross total resection without contrast enhancement in 80 % of patients. In the present experience the procedure did not determine any relevant additional neurological deficit, nor toxicity. Considering overall survival of all patients (recurrent GBM included) we obtained a median extension of at least 9.0 months (6 – 28 months).
Conclusions: Fluorescence-guided surgery improves tumor detection and allows extended resection of malignant glioma, without any relevant impact on neurological status, resulting helpful mainly in the recurrent setting with a consistent effect on overall survival
Patient Care: fluorescence-guided tumor removal reduces the residual volume tumor. Small volume tumors treated with radiotherapy or chemotherapy are associated to less toxicity and better survival
Learning Objectives: 5-ALA guided surgical resection improves survival in elderly patients even if only chemotherapy is feasible.